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Full text of "The development of a physician prospective payment system for ambulatory care"

y 



^. 



The Development of a 

Physician Prospective Payment System 

FOR Ambulatory Care 



Richard F. Averill, M.S., Principal Investigator 

Jon Eisenhandler, Ph.D., Project Manager 

Norbert I. Goldfield, M.D., Medical Director 

John S. Hughes, M.D. 

David E. Gannon, M.S. 

Boris V. Shafir, M.S. 
Laurence W. Gregg, B.S. 



This report was prepared with the support of the Health Care Financing Administration, Office 

of Research and Demonstrations, under cooperative agreement No. 17-C-90309/5-01 to 3M 

Health Information Systems. The opinions expressed are solely those of the authors, and do 

not necessarily represent those of the Health Care Financing Administration. 



For information on obtaining copies of this document, contact: 

3M Health Information Systems 

100 Barnes Road 

Wallingford, CT 06492 



(203) 949-0303 



Table of Contents 



Appendices v 

List of Figures vii 

List of Tables ix 

Acknowledgments xi 

Introduction 1 

Background on Physician Payment 3 

Overview of PCGs 3 

PCG Payment System 7 

Medicare Physician Payment Relative Value Units 9 

Database Used to Develop PCGs 9 

PCG Analysis Reports 14 

PCG Development Process 26 

PCG Payment Simulation Overview 28 

Discussion 39 

Conclusions 40 



The Development of an Episode Grouper Hi 



Final Report 



Appendices 



Appendix A Description of APGs 

Appendix B Map of Physician Specialty Codes to Specialty Categories 

Appendix C Summary of Difference Between Version 2.0 APGs and PCGs 

Appendix D List of PCGs 

Appendix E Map of HCPCS Codes to PCGs 

Appendix F Map of ICD-9-CM Diagnosis Codes to PCGs 

Appendix G PCG Payment Weights 

Appendix H PCG Pairs Excempt from Multiple Significant Procedure Discounting 

Appendix! PCG Payment S imulation Formulas 



The Development of a Physician Prospective Payment System for Ambulatory Care 



" Final Report 



List of Tables 



Table 1. 
Table 2. 
Table 3. 
Table 4. 
Table 5. 
Table 6. 
Table 7. 
Table 8. 
Table 9. 
Table 10. 
Table 11. 

Table 12. 
Table 13. 



Example of Professional Visits 5 

Examples of Construction of Visits 10 

Data editing results 14 

PCG Report 1 16 

PCG Report 2 18 

PCG Report 3 20 

PCG Report 4 22 

PCG Report 5 25 

Number to PCGs by type of PCG 27 

Extended and Limited List of Ancillary PCGs 30 

R^ for Submitted and Allowed Charges for each of the 30 PCG 

Payment Models 32 

PCG Payment Impact Models 33 

PCG Payment Impact Results 34 



The Development of a Physician Prospective Payment System for Ambulatory Care 



Final Report 



• 



Acknowledgments 



The development of the PCGs was performed in collaboration with the Health 
Care Financing Administration (HCFA). The staff of HCFA provided 
extensive input into the research: Mark Krause (HCFA Project Officer), 
Vivian Braxton, Barton McCann, Janet Wellham, Cathaleen Ahem and Gay 
Barton. In addition, this research involved the participation of many 
individual contributors. A wide range of clinicians, hospital administrators, 
regulators and researchers provided valuable input into the research. 
Assistance in the design and production of the PCG Final Report was 
provided by Marilyn Marino. 



The Development of a Physician Prospective Payment System for Ambulatory Care 



The Development of a Physician Prospective Payment System for Ambulatory Care 



Final Report 



Introduction 



Introduction 



In April of 1983, Congress enacted legislation to create the Medicare 
Inpatient Prospective Payment System (PPS). The inpatient PPS represented 
the most radical change in hospital payment methods since the creation of the 
Medicare system. Prior to the inpatient PPS, Medicare paid hospitals under a 
cost based system, essentially paying hospitals whatever they spent. As a 
result of the cost based payment system for inpatient care, medical payments 
to hospitals prior to PPS were increasing at nearly three times the overall rate 
of inflation and the solvency of the Medicare Trust Fund was in jeopardy. 

Under a PPS the payment rate received by a provider remains unchanged 
regardless of the hospital's overall cost experience. This risk generates a 
strong financial incentive for providers to control costs. The underlying 
assumption of a PPS is that the financial risks and incentives inherent in the 
system will cause providers to operate in a more cost effective manner. In 
essence, the success of prospective payment is, in part, based on shifting the 
primary responsibility for cost control from Medicare to providers. 

The unit of payment for the Medicare inpatient PPS was established as the 
discharge. Hospital casemix was quantified using the Diagnosis Related 
Group (DRG) patient classification scheme. Predetermined payment rates 
were established for each DRG. The DRG payment rates were considered 
payment in full and were not negotiable. 

Since its inception in 1983, the inpatient PPS has been successful in 
controlling the increase in Medicare expenditures for inpatient care. A study 
by the Brookings Institution concluded that expenditures from the Medicare 
Hospital Trust Fund are running substantially below the levels projected 
before PPS. The reduction in expenditures corresponds to the reduction in 
admissions, length of stay and ancillary service use that occurred after the 
implementation of PPS . These reductions have been achieved with no 
apparent impact on the quality of care'^. 

Under the Omnibus Budget Reconciliation Act (OBRA) of 1990, Congress 
directed the Health Care Financing Administration (HCFA) to develop a 
prospective payment system (PPS) for outpatient care. Section 4151(b)(2) of 
that act called for the design and modeling of a PPS for hospital outpatient 
services (e.g., emergency rooms, outpatient clinics, etc.). The outpatient PPS 
was to include only the facility payment, which refers to the hospital cost for 
providing care (e.g., room charges, medical and surgical supplies, etc.) and to 
exclude the physician's professional charge. During the period 1988-1990, 
HCFA funded the development of the initial design of an outpatient PPS-^. 

As a result of the success of the inpatient PPS, research on the design of an 
outpatient PPS closely followed the basic structure of the inpatient PPS. The 
basic unit of payment selected for the outpatient PPS was the visit. A visit is a 
contact between the patient and a health care professional. The visit could be 
for a procedure, for a medical evaluation or simply for an ancillary service 
such as a chest x-ray. For each type of visit a prospective price is established 
that includes all routine services associated with the visit. Since the cost of the 



The Development of a Physician Prospective Payment System for Ambulatory Care 



The Development of a Physician Prospective Payment System for Ambulatory Care 



routine services rendered during a visit is included in the payment for the 
visit, hospitals have a financial incentive to control the amount of services 
rendered. In order to have a visit based outpatient PPS, it was necessary to 
develop a patient classification system that could serve as the basis of 
payment. A patient classification system for outpatients would serve the same 
function as the DRGs in the inpatient PPS. As part of the research on the 
design of an Outpatient PPS an ambulatory patient classification system was 
developed. This system is called Ambulatory Patient Groups (APGs) and was 
designed to be used as the basis of payment in an outpatient PPS. APGs are a 
patient classification scheme designed to explain the amount and type of 
resources used in an ambulatory visit. Patients in each APG have similar 
clinical characteristics, similar resource use and similar cost. The APG patient 
classification system utilized the same general approach and techniques that 
were used in the development of the DRGs. The inifial design of the 
outpatient PPS was directly patterned after the inpatient PPS model. 

Version 1.0 of APGs was released in the spring of 1991. During the period 
1991-1994, a number of payors, including state Medicaid agencies and Blue 
Cross and Blue Shield plans, began using APGs for outpatient payment'*-^. In 
addition, individual providers began using APGs for internal management. 
The expanding use of APGs and the potential use of APGs as the basis of a 
Medicare outpatient PPS resulted in HCFA funding the development of 
Version 2.0 of APGs. During the period 1992-1995, Version 2.0 of APGs was 
developed. Appendix A contains a summary of the development of APGs. 

In October of 1997, Congress passed the Balanced Budget Act (BBA). The 
BBA mandated that HCFA implement a Medicare PPS for the facility portion 
of a hospital based outpatient services. In September of 1998, HCFA 
published preliminary regulations for the Medicare outpatient PPS. The basis 
of payment for the proposed Medicare outpatient PPS was a modification of 
Version 2.0 of APGs called Ambulatory Payment Classification (APC)^. 
Implementation of the Medicare outpatient PPS is planned to occur in the year 
2000. 

Both the DRG based inpatient PPS and proposed APC based outpatient PPS 
include only facility costs and excluded professional costs. In October of 
1994, HCFA funded a project to expand APGs to encompass professional 
services as well as facility costs. The primary objective of the project was to 
develop a new patient classification system that could be used as the basis of a 
PPS for ambulatory physician services. The new patient classification system 
was to extend the previously developed APG patient classification system to 
include both the professional and the facility component of ambulatory 
services and to include settings beyond hospital outpatient departments such 
as physician offices. The extension of APGs to encompass the professional as 
well as the facility component of ambulatory care is referred to as Physician 
Care Groups (PCGs). The development of PCGs was based on an analysis of a 
comprehensive Medicare ambulatory physician payment database. 

The modifications made to Version 2.0 of APGs to create APCs focused 
exclusively on facility costs. To the extent possible, the development of PCGs 



Final Report 



Background on Physician Payment 



incorporated the enhancement to APGs associated with the development of 
APCs. 



Background on Physician Payment 

Between FY 1990 and FY 1995, Medicare supplementary medical insurance 
disbursements to physicians and suppliers increased from $42,468 million to 
$64,973 million which is a 53% percent increase^. The Omnibus Budget 
Reconciliation Act of 1989 (OBRA 1989) directed the Medicare program to 
pay for physician services using a resource based fee schedule. 
Implementation of the Medicare Fee Schedule for physician payment began 
January 1, 1992. 

The Medicare Fee Schedule is composed of two components. 

1. A relative value unit scale (RVU) which gives a relative weight for 
physician work, practice expense and malpractice expense for all 
services paid by Medicare. The physician work RVUs were developed 
through surveys of physicians on the time, intensity and total work 
required to perform a large number of services and procedures^. 
Specialty panels of physicians provided technical advice on the survey 
questionnaire utilized. The practice expense and malpractice expense 
RVUs were originally calculated from historical charge levels through 
formulas specified in the OBRA 1989 but are being converted to 
resource-based. 

2. Geographic adjustment factors and other payment adjustments which are 
applied to the RVUs to obtain a payment rate. 

The codes contained in the HCFA Common Procedure Coding System 
(HCPCS) are used by physicians to specify the services provided. HCPCS 
codes include all Current Procedure and Terminology (CPT) codes published 
by the American Medical Society , HCFA developed national codes for drugs, 
supplies and other services and local codes used by the Medicare fiscal 
intermediaries. While procedure codes did not dramatically change as a 
consequence of the adoption of the Medicare fee schedule, codes for 
diagnostic services (evaluation and management or E&M codes) underwent 
significant change in description. Although there was a change in the verbal 
description of the HCPCS codes for diagnostic services, the axis of 
classification (i.e., physician work or effort) remained the same. 



Overview of PCGs 

The objective of the development of PCGs was to create a patient 
classification system that explained the amount and type of professional 
services utilized in ambulatory settings. Ambulatory settings include 
physician offices, hospital outpatient departments, hospital emergency rooms, 
ambulatory surgical centers, community mental health centers. 



The Development of a Physician Prospective Payment System for Ambulatory Care 



The Development of a Physician Prospective Payment System for Ambulatory Care 



comprehensive outpatient rehabilitation facilities, state or local public health 
facilities and rural health clinics. Currently, the methods for determining 
payment for professional services across different ambulatory setting is 
inconsistent and confusing. PCGs can provide a uniform basis for paying 
professional services across all ambulatory settings. PCGs are limited to 
professional services provided in an ambulatory setting and do not include 
professional services provided on an inpatient basis. Like APGs, PCGs are a 
visit-based patient classification system. 

As depicted in Figure 1, there are multiple service components to a 
professional visit. Central to the professional visit are the direct physician 
services associated with the time and effort of the physician. The physician 
time and effort are associated with the treatment of the patient and include 
services such as performance of a procedure, establishing a diagnosis and 
patient counseling. 




Figure 1. Service Components of a Professional Visit 

In addition to direct physician services, a professional visit may also include 
the following services. 

Technical Services 

Technical services involve the use of specific equipment in the diagnosis 
or treatment of a patient. The equipment may not be used directly by the 
physician, but may be used by support staff such as a technician. The 
performance of an ECG is an example of a technical service. 

Technical Interpretation 

Some technical services require physician interpretation of the results 
(e.g., reading an ECG). The technical interpretation may be performed by 
a physician other than the professional who provided the technical 
service. 

Facility Services 

Facility includes building space, routine supplies, nursing services and 
other services necessary to support the professional service. 

Ancillary Services 

Ancillary services are tests that may be provided as part of a visit but are 
usually not performed by the physician (e.g., blood tests). 



Final Report 



Overview of PCGs 



A professional visit may include all or only some of the different service 
components of a professional visit. The site of service can in part, determine 
which service components are included in the professional compensation. 
Payment for professional services rendered in a physician's office would 
include compensation for the costs associated with facility services. However, 
if the same services were delivered by the physician in an institutional setting 
such as a hospital ER, then the professional compensation would not include 
full compensation for facility services. Since under the proposed Medicare 
outpatient PPS the hospital would bill separately for the facility component, 
only a portion of the facility service would be included in the physician 
compensation to cover administrative expenses such as billing. 

Table 1 provides examples of professional visits with different service 
components. The first example in Table 1 is a visit for pneumonia for which 
the care was provided in a hospital outpatient department. In this example, the 
professional compensation would be primarily for the professional service 
and would not include full compensation for facility costs. The second 
example is the same pneumonia visit occurring in the physician's office. In 
this example there would be full compensation for the facility cost. In the 
third example, there was an office visit for pneumonia and during the office 
visit a chest film was taken and interpreted by the physician. In this example, 
there would be additional compensation for the technical service (i.e., the 
chest film) and the technical interpretation (i.e., reading the chest film). In the 
fourth example, a white blood count (WBC) was also performed so there 
would be additional compensation for the WBC. In the fifth example, a chest 
film was performed elsewhere and the only physician service was the reading 
of the chest film. In this example, the only physician compensation would be 
for the technical interpretation associated with the reading of the chest film. In 
the last example, the physician performed the chest film and interpreted the 
chest film and therefore, the physician compensation would include both the 
technical service and the technical interpretation. Since different physicians 
can provide different service components associated with a professional visit, 
PCGs must be able to differentiate the individual service components of a 
professional visit. In particular, it is essential that PCGs be able to 



Prof 
Service 


Facility 


Technical 
Interpretation 


Technical 
Service 


A DC 


Example 


X 










OPD visit for pneumonia 


X 


X 








Office visit for pneumonia 


X 


X 


X 


X 




Office visit for pneumonia 
with office chest film 


X 


X 


X 


X 


X 


Office visit for pneumonia 
with chest film and WBC 






X 






Reading of chest film per- 
formed elsewhere 






X 


X 




Performing and reading 
chest film 



Table 1. Example of Professional Visits 



The Development of a Physician Prospective Payment System for Ambulatory Care 



The Development of a Physician Prospective Payment System for Ambulatory Care 



differentiate the individual service components of a professional visit because 
the service components that are included in the physician compensation vary 
depending on the site of service. 

Since facility and certain technical services correspond to the facility 
component in APGs, Version 2.0 of the APGs were used as the starting point 
for the development of PCGs. In the APG system, there are four types of 
APGs: significant procedure, medical, ancillary and incidental (See appendix 
A). A significant procedure is a procedure that is normally scheduled, 
constitutes the reason for the visit and dominates the time and resources 
expended during the visit. All patients who have a significant procedure 
performed are assigned to APGs based on the significant procedure. All 
medical services provided to the patient are assumed to be an integral part of 
the significant procedure. Patients with no significant ambulatory procedures 
who received medical services are assigned to medical APGs. The presence of 
an E&M code is used to indicate that a patient received medical services. 
Medical APGs are assigned primarily based on the diagnosis that is reported 
as the patient's reason for the visit. Patients with no significant procedures and 
no medical services, who only have ancillary services (e.g., a chest x-ray), are 
described by a list of ancillary APGs corresponding to the ancillary services 
provided. Incidental services are an integral part of a significant procedure or 
medical visit and would not result in additional physician compensation. Like 
APGs, there are significant procedure, medical, ancillary and incidental 
PCGs. However, in the PCG system, a fifth type of PCG is defined and is 
referred to as professional ancillary. An ancillary service is a test or procedure 
that is ordered by the primary physician to assist in patient diagnosis or 
treatment. Some ancillary services do not require physician effort (e.g., blood 
tests) while other ancillary services include significant physician involvement 
(e.g., radiology procedures). PCGs that related to ancillary services involving 
direct contact between the patient and physician constitute a separate type of 
PCG referred to as professional ancillary. 

Thus, the underlying structure of PCGs is similar to APGs in several 
important ways: 

• Like APGs, there are PCGs for significant procedures, medical visits, 
ancillary services and incidental services. 

• Like DRGs and APGs, medical PCGs are based on the patient's condition 
(i.e., diagnosis) and not reported physician effort (i.e., E&M code). 

• Like APGs, a patient can be assigned to multiple PCGs. 

While PCGs have many structural similarities to APGs, there are some major 
differences. The most significant structural difference is that in order to 
differentiate the different service components associated with a professional 
visit, it is necessary to subdivide those PCGs that represent a technical 
service, which is separable, into a technical and professional service 
component. Therefore, in the PCG system, each PCG also has a service class 
that specifies the individual components of a technical service. The service 
class values are: 



Final Report 



PCG Payment System 



• Complete service 

• Professional service only 

• Technical service only 

The individual HCPCS codes assigned to a PCG can have different service 
classes. For example, the following two HCPCS codes are both assigned to 
the electrocardiogram PCG. 

93005 Electrocardiogram routine ECG with at least 12 leads, 

tracing only without interpretation and report 

93010 Electrocardiogram, routine ECG with at least 12 leads, 

interpretation and report only 

If HCPCS code 93005 is reported it will be assigned to the electrocardiogram 
PCG with a service class of technical service only. If HCPCS code 93010 is 
reported it will be assigned to the electrocardiogram PCG with a service class 
of professional service only. 

While the service class of a particular HCPCS code within a PCG can 
sometimes be determined directly from the HCPCS code, this is not possible 
for all HCPCS codes. In addition to the HCPCS code itself, up to two HCPCS 
code modifiers may also be reported along with the HCPCS code. Modifiers 
are two character codes. The modifier "26" indicates that the service 
associated with the HCPCS code was professional only, and a modifier of 
"TC" indicates that the service associated with the HCPCS code was technical 
only. When modifiers are reported they are used by PCGs to determine the 
service class. Thus, within the same PCG, the service class may differ 
depending on the specific HCPCS code used to assign the PCG or the 
presence of a "26" or "TC" modifier. For example, if the HCPCS code 79010 
for thyroid imaging is reported with a modifier of "26" it indicates that only 
the professional component of the thyroid imaging was provided by the 
physician. A modifier of "TC" indicates that only the technical component of 
the thyroid imaging was provided. If no modifier is present, then the thyroid 
imaging represents the complete service. It should be noted that only those 
PCGs that represent a separable technical service are subdivided into a 
technical and professional component. The majority of HCPCS codes always 
have a service class that represents the complete service. 



PCG Payment System 



In the PCG payment system, a patient is described by a list of PCGs that 
correspond to each service provided to the patient. The assignment of multiple 
PCGs to a patient is similar to APGs but is in contrast to the DRGs which 
always assign a patient to a single DRG. In the ambulatory setting, the 
diversity of sites of service (i.e., same day surgery units, ERs and physician 
offices) and the wide variation in the reasons patients require care (e.g., 
ranging from well care to critical trauma care) necessitates a patient 
classification system that can reflect the diversity of professional services 



The Development of a Physician Prospective Payment System for Ambulatory Care 



The Development of a Physician Prospective Payment System for Ambulatory Care 



rendered to the patient. PCGs address the diversity of professional services 
within the ambulatory setting in two ways: 

• PCGs that represent a technical service can have multiple service classes. 
The service class recognizes that the components of a technical service 
included in professional compensation can differ depending on the nature 
of the services provided or on the site of service. 

• Multiple PCGs can be assigned to a patient. The assignment of multiple 
PCGs recognizes that the volume of services for the same type of patient 
can vary depending on the needs of the patient (e.g., a patient may have 
two unrelated procedures during the same visit) or on the site of service 
(e.g., more extensive testing will typically be performed in an emergency 
room than in a physician office). 

In a PCG-based PPS, each PCG and corresponding service class would have a 
standard payment rate and the payment for a patient would be computed by 
summing the payment rates across PCGs and corresponding service classes 
assigned to the patient. However, in summing the payment rates across PCGs 
and corresponding services classes, two types of discounting are applied. 

Multiple Significant Procedure Discounting 

When multiple significant procedures are performed, a discounting of the 
PCG payment rates is applied. Multiple significant procedure discounting 
refers to a reduction in the standard payment rate for significant procedure 
PCG. Multiple significant procedure discounting recognizes that the 
marginal cost of providing a second procedure to a patient during a single 
visit is less than the cost of providing the procedure by itself. The most 
expensive significant procedure PCG is paid at 100 percent of the 
standard PCG payment rate and all other significant procedure PCGs are 
paid a percentage of the standard PCG payment rate. 

Site of Service Discounting 

Payment for professional services rendered in a physician's office would 
include full compensation for the costs associated with all service 
components. However, if the same services were delivered by the 
physician in an institutional setting such as a hospital ER, then the 
professional compensation would not include full compensation for 
facility costs since the hospital would bill separately for the facility 
service component. Site of service discounting refers to a reduction in the 
standard payment rate for a PCG and corresponding service class when 
the site of service is an institutional setting and not the physician office. 
The site of service discount represents a reduction in the facility portion 
of the payment rate. 

Figure 2 provides an overview of the PCG payment system. 















Sum Payment 

Weights Applying 

Significant Procedure 

Discounting and Site 

of Service Discounting 






Visit 




Assign PCGs 

and Service 

Classes 




Payment Weights 
by PCG and 
Service Class 




Final 

PCG 

Payment 





























Figure 2. PCG Payment System 



Final Report 



.Vl%">=.. 



Medicare Physician Payment Relative Value Units 



Medicare Physician Payment Relative Value Units 

The RVU values used in the development of the PCGs come from the 1995 
National Physician Fee Schedule Relative Value File (commonly referred to 
as RBRVS for resource-based relative value scale). The 1995 file was used 
rather than the 1994 file because the 1994 Physician/Supplier file included 
substantial numbers of claims coded with 1 995 procedure codes (codes in 
effect at the time of claim submission) that were not included in the 1994 
RBRVS file. Two options of handling 1995 codes used for reporting 1994 
services were considered. The first was to supplement the 1994 RBRVS file 
with 1995 RBRVS values for new codes. The second was to use only one of 
the files, the 1995 file, because it included the new codes. It was decided to 
take the latter option, in order to avoid introducing unknown problems and 
biases when averaging RVU values from two different years. 

There is one record on the RBRVS file for every unique combination of a 
HCPCS code and a modifier field indicating whether or not the HCPCS code 
and modifier were for a professional only component (modifier 26), a 
technical only component (modifier TC), or complete service (both 
components). The RBRVS file includes a breakdown of each RVU into three 
components, (work or professional, practice expense, and malpractice), and 
other fields affecting payments such as whether or not the code could be 
submitted for partial reimbursement, assistant at surgery, etc. Not all HCPCS 
codes have RVU values in the RBRVS file. For example, HCPCS codes that 
represent poorly defined services (referred to as "unlisted" procedures in 
HCPCS) do not have an RVU value and therefore, are not paid by Medicare 
under RBRVS. In order to create a complete RVU file, RVU values were 
estimated for HCPCS codes with missing RVU values. For those HCPCS 
codes without assigned RVUs in the RBRVS file, RVU values were 
extrapolated from those codes in the same PCG that had RVUs assigned. 
Using those HCPCS codes within the PCG that had RVU values, the ratio of 
RVUs to allowed charges was computed. This ratio was applied to the allowed 
charges for HCPCS codes within the PCG without RVU values in order to 
estimate RVU values for those codes. If all HCPCS codes in a PCG had no 
RVUs assigned (e.g., the anesthesia PCGs have no RVUs because anesthesia 
is not paid under RBRVS), the ratio of RVUs to allowed charges is set at the 
average value across all other PCGs of the same type (i.e., significant 
procedure, professional ancillary or ancillary). The final RVU file used in the 
analysis had work, practice and malpractice RVUs for each HCPCS code and 
service class. It is necessary to have separate RVUs for work, practice and 
malpractice in order to implement the site of service discounting. 

Database Used to Develop PCGs 

The claims data used in the PCG analysis are from the 5% Standard 
Analytical File (SAF) for the 1994 Physician/Supplier Part B File. This file 
included claims for 1994 Medicare Part B services that were processed 



The Development of a Physician Prospective Payment System for Ambulatory Care 



The Development of a Physician Prospective Payment System for Ambulatory Care 



between January 1, 1994 and June 30, 1995. Thus, the date of service of all 
claims in this file is 1994, although the claim may have not been submitted for 
payment until 1995. The Physician/Supplier file contains claims submitted 
using HCFA 1500 claim forms and supplemented by data added during 
processing (e.g., payments, edits, reporting categories, etc.). All unique 
identifiers on this file were encrypted. Although the identifiers were 
excerpted, they were encrypted in a consistent manner which allowed claims 
from an individual beneficiaries to be linked together. 

The unit of analysis for PCGs is the ambulatory visit. A visit consists of all 
services performed for one patient by a single provider at a single site on the 
same day. In its most common form a visit consists of an office visit and any 
billable supplies, laboratory work, pharmaceuticals, etc., provided to a patient 
by the same physician on the same day at the same site of service. Physicians 
performing services for the same patient at multiple sites will be defined as 
having multiple visits. For example, a physician who treats a patient in his/her 
office and later treats the same patient in a hospital outpatient department will 
have two visits. 

Data in the Medicare Physician/Supplier file are submitted as claims that do 
not necessarily represent a visit. A claim can contain services from several 
visits or can contain only some of the services from a single visit. Claims are 
composed of line items. Each line item describes a specific service and 
includes the following information: HCPCS code with optional modifiers 
describing the service, ICD-9-CM diagnosis code describing the reason the 
service was performed, number of times the service was performed, date of 
service, provider identification, site of service and submitted and allowed 
charges. The overall claim contains information on the pafient including 
demographic informafion and a unique patient identifier. Visit records were 
constructed from line item claim data on the Physician/Supplier file. To build 
a visit record, claims were broken down to the line item level. The line item 



A claim is submitted with a single line for a sin- 
gle procedure or evaluation and management ser- 
vice with no other services. 


A single visit is defined. 


A claim has multiple lines of data consisting of a 
single professional service and some other ser- 
vices (e.g., minor lab procedures or medical sup- 
plies) incurred at the same site on the same day 
by the same provider. 


A single visit is defined. 


A claim has multiple lines of data consisting of 
professional services performed on different 
days. 


Each of the different dates of 
service create a different visit. 


Several claims are submitted for services ren- 
dered on a single visit, on a single day, for a sin- 
gle provider. 


Claims collapsed into a single 
visit. 



Table 2. Examples of Construction of Visits 



10 



Final Report 



Database Used to Develop PCGs 



o 



records were merged such that all lines with an identical patient identifier, 
provider identification number, date of service, and site of service were linked 
to create a visit record. Single claims that contained data for multiple visits 
were split into multiple visits. If services associated with a single visit were 
present on multiple claims, then their services were aggregated into a single 
visit. Table 2 contains examples of how visits are constructed using the data 
from the Physician/Supplier File. 

The Physician/Supplier file contained 28,416,678 ambulatory physician 
claims containing 36,612,391 Unes representing 1,577,467 different 
..beneficiaries. The process of consolidating and desegregating claims into 
visits resulted in 17,983,463 visits. 

Typically, visits consist of multiple lines representing the different services 
provided during the visit. The lines for the visits may have been submitted on 
different claims. In order to assign a PCG it is necessary to identify the 
primary procedure or diagnosis that describes the visit. The most significant 
line (MSL) was identified for each visit. The MSL for a visit was determined 
as follows: 

• If a significant procedure was present, the MSL was the most expensive 
professional or complete significant procedure 

• If there were no professional or significant procedures, the MSL was the 
most expensive technical significant procedure 

• If there were no significant procedures present, the MSL was the HCPCS 
E&M code (As a result of the editing, there can be only one E&M code 
per visit) 

• If there were no significant procedures or E&M code present, the MSL 
was the most expensive professional or complete professional ancillary 

• If there were no significant procedures, E&M code or professional or 
complete professional ancillary present, the MSL was the most expensive 
professional ancillary technical service 

• If there were no significant procedures, E&M code or professional 
ancillary present, the MSL was the most expensive ancillary or incidental 
service present 

Medical PCGs are assigned based on a single diagnosis. Since a patient can 
have multiple diagnoses reported (i.e., one for each Hne), the MSL was used 
to select the diagnosis of the medical PCG. Thus, the diagnosis associated 
with the line with the E&M code was used to assign the medical PCG. 

Once the claims data were converted to visits and the MSL identified, a series 
of 33 different types of edits were applied to the visit data. The occurrence of 
any of these edit resulted in the whole visit being excluded from the analysis. 
The edits were as follows: 

1. Invalid Date An invalid date is a date which is invalid as a date (e.g., in- 
valid characters or combinations of numbers such as the day of the 
month equaling 35 or the number of the month equahng 15). 



The Development of a Physician Prospective Payment System for Ambulatory Care 11 



The Development of a Physician Prospective Payment System for Ambulatory Care 



2. Date Out Of Range Date out of range occurs when an otherwise valid 
date of service is for any year other than 1994. 

3. Invalid Beneficiary ID An invalid ID is a beneficiary ID which has any 
invalid characters or represents a sequence of characters that is invalid as 
a beneficiary ID. 

4. Inconsistent Sex Inconsistent Sex occurs when the beneficiary sex code 
is not identical for all the lines of a visit. 

5. Missing Physician TaxID The tax identification number is missing 
(blank) on any line on the visit. 

6. Conflicting Physician TaxID and UPIN Invalid or inconsistent TaxIDs 
or UPINs on a visit. The 1994 Physician/Supplier data lacked a single 
universal physician identifier. The TaxID and uniform provider identifi- 
cation number (UPIN) were used to identify the physician. 

7. Contradictory HCPCS Modifiers Services which are subject to both 
professional and technical modifiers as identified in modifier field in the 
RVU file must be clearly identifiable as being for either a professional, 
technical, or complete service. If the two fine item modifier fields have 
values of 'TC and '26' (both technical and professional components) in 
either order, the type of service is not identifiable. 

8. Unavailable RVU If the service associated with a HCPCS code has a 
professional and technical component, but there are no RVUs for the 
code in the RVU file, the RVUs for the professional and technical com- 
ponent can not be computed. 

9. Inconsistent Dates A line on a visit has a missing or invalid through date 
or a line for which the from date does not equal the through date. 

10. No Paid Services A visit does not have at least a single line with the al- 
lowed charges greater than 0. 

11. Multiple E&M Codes A visit has two or more E&M codes (i.e., two or 
more medical visits) of which two or more have allowed charges greater 
than 0, or an E&M with allowed charges greater than is for more than 
one unit of service. 

12. Significant Procedure and E&M Present A visit has bodi a significant 
procedure line and a E&M code (i.e., medical visit) and both have al- 
lowed charges greater than 0. 

13. MSL is Technical Service The most significant line of a visit is a techni- 
cal service. 

14. Partial Payment Visits with lines for partial payment of professional 
services (significant procedures, medical visits, or professional ancil- 
lary). Some procedures which are rendered over an extended period of 
time have a provision for the proration of payments between professional 
providers for what is considered to be a single service for the purposes of 
payment. In such cases payments may, though not necessarily, be spHt 
between providers and reimbursement prorated in a predetermined fash- 
ion. Partial services can be identified by one of three HCPCS modifiers, 
54 (surgery/procedure only), 55 (postoperative care only), and 56 (preop- 



o 



12 



Final Report 



■s*f»«*«:v 



Database Used to Develop PCGs 



erative care only). If a procedure which can be paid on a partial basis is 
present with a modifier of 54, 55, or 56, the visit was excluded from the 
analysis. 

15. Assistant at Surgery Visits with lines for surgical assistants. If the mod- 
ifier codes associated with a line equal 80, 81, or 82, the visit is for a sur- 
gical assistant. 

16. Medicare Not Primary Payer Medicare is a secondary payer for any 
line. 

17. Out-of-Date HCPCS Code An out-of-date HCPCS code for any Une. 
Visits including lines with codes eliminated prior to January 1 , 1 994 and 
not re-implemented prior to January 1, 1997 or codes not implemented 
until after December 31,1 996. 

18. Local HCPCS Code Any line having a HCPCS Level 3 code (first char- 
acter of the HCPCS code starts with a W,X,Y, or Z). 

19. HCPCS Code with Inconsistent Site of Service Any line in a visit with 
HCPCS code for a site of service which is inconsistent with the site spec- 
ification of this analysis. For example, a visit with a line with a HCPCS 
code of 99341, (home visit for the evaluation and management of a new 
patient). 

20. Age and Diagnosis Conflict Age conflicts with line item diagnosis. 

21. Sex and Diagnosis Conflict Sex conflict with line item diagnosis. 

22. Sex and Procedure Conflict Sex conflicts with procedure. 

23. Excess Lines A visit with more than 50 lines. 

24. Excess Paid Services A visit with more than 25 lines with allowed 
charges greater than 0. (Note that not all lines have charges). 

25. Capitated Payment The type of service indicates an end stage renal dis- 
ease capitated payment for any hne. 

26. Invalid HCPCS Code An invalid HCPCS code. 

27. Inpatient Procedure A HCPCS code which is a procedure that can only 
be performed on an inpatient basis (e.g., coronary bypass). 

28. Autopsy Services A HCPCS code which is an autopsy service. 

29. Non Covered Services A HCPCS code which is a service not covered by 
Medicare. 

30. Invalid Diagnosis Code Medical visits for which the ICD-9-CM diagno- 
sis code on the MSL was invalid or out-of-date. 

31. E-Code on MSL Medical visits for which the ICD-9-CM diagnosis code 
on the MSL was an E-Code (i.e.. description of accident which caused a 
trauma). 

32. Diagnosis Requires a Procedure Medical visit for which the ICD-9-CM 
diagnosis on the MSL was a diagnosis that requires a procedure (i.e., 650 
normal delivery of a newborn). 

33. Ungroupable, No PCGs Assigned No professional services rendered 
(i.e., no PCGs assigned). 



The Development of a Physician Prospective Payment System for Ambulatory Care 13 



The Development of a Physician Prospective Payment System for Ambulatory Care 



If edits 1-6 or 9 occur, accurate visit construction is not possible. If edits 11- 
1 3 or 33 occur, the reason for the visit is poorly defined and appropriate PCGs 
can not be assigned. Edits 14, 16, 25 and 29 indicate that all the charges 
associated with the visit may not be present. Edits 17-22, 26-28 and 30-32 
indicate that the diagnoses or procedures are questionable which could result 
in inaccurate PCG assignment. Edits 23 and 24 represent an excessive number 
of services which may indicate an inaccuracy in the visit construction. Edits 7 
and 8 are related to difficulties with the identification of the technical and 
professional components. 

The occurrence of any of the above edits caused the whole visit to be excluded 
from the analysis. In addition, any line for a professional service that had 
allowed charges equal to zero (i.e., the code for the service was submitted but 
for some reason, no payment was made) was excluded from the analysis. 
Although the individual line was excluded from the analysis the rest of the 
visit was not excluded. 

Table 3 contains the number of visits and lines for which each edit occurred. 
There are 3,534,825 edits that occurred. More than one edit can occur on a 
visit. There were 2,888,721 visits (16.6 percent) with one or more edits. The 
application of the edits reduced the number of visits in the analysis database 
from 17,983,463 to 14,994,742. 



PCG Analysis Reports 



In order to facilitate the analysis of the physician database, a series of PCG 
analysis reports was produced. The PCG analysis reports detailed information 
on each HCPCS code that comprises a significant procedure PCG, 
professional ancillary PCG or ancillary PCG, and each ICD-9-CM diagnosis 
code that comprises a medical PCG. The information on each HCPCS or ICD- 
9-CM code contained in the PCG analysis reports include frequency of 
occurrence, site of service, average allowed professional charge, average 
submitted professional charge, RVU values, type of service, medical specialty 
and outpatient facility cost. 

Table 4 contains PCG Report 1 which examines the frequency, site of service 
and charges associated with the HCPCS codes that comprise each significant 
procedure PCG. HCPCS codes with multiple service classes will have a 
separate line in the report for each service class. PCG Report 1 is comprised 
of a data section and a description section. The data section consists of a row 
for each HCPCS code in the PCG whether or not the code has any data.The 
report is sorted by frequency. 

The data section of Report 1 consists of the following columns: 

1. SEQ A set of sequence numbers are assigned consecutively to each 
line and are numbered starting with the number 1. These numbers are 
used to link the lines in the data section of the report with a descrip- 
tions of the procedure associated with the HCPCS code. 



14 



Final Report 



■^ V f ■•%■ 



PCG Analysis Reports 



Edit 


Visits 


Lines 


Description 


1 








Invalid date 


2 


66 


106 


Date out-or-ranges 


3 








Invalid beneficiary ID 


4 


130 


453 


Inconsistent sex 


5 


1,675 


3,693 


Missing physician TAXID 


6 


296,509 


1,217,591 


Conflicting physician TAXID and UPIN 


7 


86 


339 


Contradictory HCPCS modifiers 


8 


15,183 


87.473 


Unavailable RVU 


9 


139,500 


230,309 


Inconsistent dates 


10 


700,925 


1,265,181 


No paid services 


11 


74,959 


259,999 


Multiple E&M codes 


12 


654,286 


2,989,977 


Significant procedure and E&M code present 


13 


53,422 


103,223 


MSL is technical service 


14 


20,373 


30,138 


Partial payment 


15 


5,855 


13,998 


Assistant at surgery 


16 


473,760 


1,100,226 


Medicare not primary payer 


17 


15,048 


77,475 


Out-of-date HCPCS code 


18 


53,137 


199,125 


Local HCPCS code 


19 


15,633 


37,610 


HCPCS code with inconsistent site of service 


20 


2,595 


7,173 


Age and diagnosis conflict 


21 


4,105 


13,134 


Sex and diagnosis conflict 


22 


626 


2,158 


Sex and procedure conflict 


23 


391 


28.000 


Excess lines 


24 


1,311 


45.016 


Excess paid services 


25 


34 


36,728 


Capitated payment 


26 


78,604 


318.048 


Invalid HCPCS code 


27 


6,360 


15.458 


Inpatient procedure 


28 


14 


64 


Autopsy services 


29 


249,070 


555,822 


Non covered services 


30 


631,855 


1,434,889 


Invalid diagnosis code 


31 


1,527 


1,757 


E-Code on MSL 


32 


350 


698 


Diagnosis requires a procedure 


33 


2,909 


12,479 


Ungroupable, no PCGs assigned 


Total 


3,534,825 


10,086,340 





Table 3. Data editing results 



The Development of a Physician Prospective Payment System for Ambulatory Care 



15 



The Development of a Physician Prospective Payment System for Ambulatory Care 



2. HCPCS The HCPCS code number. 

3. MOD The Modifier column identifies whether the code represents is a 
professional (26), technical (TC), or complete service. 

4. FREQUENCY Frequency is the number of occurrences of the 
HCPCS and modifier combination with allowed charges greater than 
0. The exception to this is the Anesthesia PCGs (335, 336, and 337). 
For these PCGs, frequency equals the numbers of occurrences includ- 
ing those for which allowed charges were zero. If a HCPCS code has 
no occurrences frequency is reported as zero. 

5. - P_TOT is the percent of occurrences within a given PCG which are 

associated with a HCPCS and modifier combination. 
6-10. % SITE OF SERVICES There are five sites of services: physician 
office (OFF), outpatient department (OPD), emergency room (ER), 
ambulatory surgery center (AMB), and other (OTH). Within each line 
the percent of occurrences for each site is calculated such that their 
sum equals 100% within the line. 

11-14. RVUs The RVU values are from the RBRVS file using the work 

(WORK), practice (PRAC), malpractice (MALPR) and total (TOT) 
fields of the 1995 RBRVS file associated with the HCPCS and modifi- 
er of the line. When there are no RVUs available, estimated RVUs are 
displayed or if they can not be calculated a blank will be displayed. 

15. AVG_ALOW Average allowed charge is the sum of the allowed 
charges (untrimmed) for the HCPCS code divided by the number of 
occurrences of the HCPCS code (Frequency). 

16. AVG_SUB Average submitted charge is the sum of the submitted 
charges (untrimmed) for the HCPCS code divided by the number of 
occurrences of the HCPCS code (Frequency). 

At the bottom of Report 1 is a detailed description of each HCPCS code in the 
report. The HPCPS code description section of the report consists of the 
following columns sorted in HCPCS code order: 

1 . SEQUENCE Sequence number. 

2. HCPCS Code number. 

3. YEARS Years for which the code is valid. 

4. Description Text description of the HCPCS code. 

The sequence number provides a link between the data section of Report I 
and the description section. 

Table 5 contains PCG Report 2 which examines the frequency and type of 
visit associated with the ICD-9-CM diagnosis codes that comprise each 
medical PCG. Report 2 is comprised of a data section and a description 
section. The data section consists of a row for each ICD-9-CM diagnosis code 
in the PCG. All diagnoses in a PCG are included in PCG Report 2 for the 
calculation of totals. 

The data section of PCG Report 2 consists of the following columns: 



16 



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Final Report 



■ ■'•'ii\f r^WKM • 



PCG Analysis Reports 



1. SEQ. A set of sequence numbers are assigned consecutively to each 
line in the report. Lines are numbered starting with the number 1 . 
These numbers are used to link the rows in this section of the report 
with a description of the diagnosis associated with the ICD-9-CM 
code. 

2. DGNS. The ICD-9-CM diagnosis code number. 

3. FREQUENCY. Frequency is the number of occurrences of the ICD- 
9-CM code. Since there is a single medical PCG per visit, frequency 
reflects the number of medical visits per diagnosis. 

4-8. % PATIENTS TYPE SERVICE. The percent of total occurrences of 
the ICD-9-CM codes that occurred in each of the five service types: 
NEW, OLD, CON (consult), ER (emergency room) and OTH (other). 
The type of service are determined by HCPCS code as follows: 



Service Type 


Codes 




NEW 


9920] - 99205. 




OLD (Established) 


99211 -99215. 




CON 


99241-99245,99271 


-99275 


ER 


99281 - 99285 




OTH 


All others. 





9-13. % OLD PATIENT SERVICE. For established patient visits the per- 
cent of total occurrences of each ICD-9-CM code is broken down in 
further detail by HCPCS code with one column per code (992 1 1 , 
99212, 99213, 99214, and 99215). The individual HCPCS codes rep- 
resent different levels of physician effort. Within each line, the percent 
occurrence across the five HCPCS codes sum to 100%. 

14-18. % SITE OF SERVICE. The percent of total occurrences of each 

ICD-9-CM code by Site of Service for the following sites: physician 
office (OFF), outpatient department (OPD), emergency room (ER), 
ambulatory surgery center (AMB), and other (OTH). Within each line 
the percent of occurrences for each site and is calculated such that 
their sum equals 100% within the hne. 

At the bottom of PCG Report 2 is a detailed description of each diagnosis 
code in the report. The ICD-9-CM code description section of PCG Report 2 
consists of the following columns sorted in ICD-9-CM code order: 

1 . SEQUENCE Sequence number 

2. DGNS ICD-9-CM code number 

3. YEARS Years for which the code is valid 

4. DESCRIPTION Text description of ICD-9-CM code 

Table 6 contains PCG Report 3 which identifies the three most common 
medical specialties associated with each HCPCS or ICD-9-CM diagnosis 
code for significant procedure and medical PCGs, respectively. The three 



The Development of a Physician Prospective Payment System for Ambulatory Care 19 



The Development of a Physician Prospective Payment System for Ambulatory Care 



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Final Report 



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PCG Analysis Reports 



most frequently occurring specialties, as determined by the frequency of 
occurrence are displayed. PCG Report 3 is comprised of a data section and a 
description section. The data section consists of a row for each ICD-9-CM or 
HCPCS code in the PCG. PCG Report 3 is produced separately for Significant 
Procedure PCGs and for Medical PCGs. In PCG Report 3 provider specialty 
codes were collapsed into 12 categories as described in Appendix B. All 
diagnoses and procedures in a PCG are included in PCG Report 3 for the 
calculation of totals. 

The data section of PCG Report 3 consists of the following columns: 

1. SEQ A set of sequence numbers are assigned consecutively to each 
line in the report. Lines are numbered starting with the number 1 . 
These numbers are used to link the rows of this section in the report 
with a description of the significant procedure or diagnosis. 

2. HCPCS or DGNS The HCPCS or ICD-9-CM diagnosis code. 

3. MOD The Modifier column identifies whether this is a professional 
(26) or technical (TC) service, or complete service. 

4. FREQ The number of occurrences of the HCPCS or ICD-9-CM diag- 
nosis code. 

5. T_RVU The total RVU associated with the significant procedure or di- 
agnosis. 

The following columns (6 - 10) repeat three times, once for each of the three 
most frequently occurring sp)ecialties in descending order: 

6. SP The specialty number associated with the HCPCS code. 

7. DESC TITLE An abbreviated description of the specialty. See Ap- 
pendix B for a complete description. 

8. P_ TOT The percent of total occurrences of the HCPCS or ICD-9-CM 
code that occurred with the specialty. 

9. P_TOT$ The percent of total allowed charges for the HCPCS or ICD- 
9-CM codes that occurred with the specialty. 

10. P_OFF The percent of total occurrences of the HCPCS or ICD-9-CM 
code that occurred in the office. 

At the bottom of PCG Report 3 is a detailed description of each HCPCS or 
ICD-9-CM code. The HCPCS or ICD-9-CM description in PCG Report 3 is 
the same as PCG Report 1 for HCPCS codes and the same as PCG Report 2 
for ICD-9-CM codes 

Table 7 contains PCG Report 4 which examines the services associated with 
physician office visits. PCG Report 4 was produced for each medical and 
significant procedure PCG. For each ICD-9-CM code for medical PCGs and 
for each HCPCS code for significant procedure PCGs, a breakdown of the 
services provided during the visit is shown. PCG Report 4 is composed of a 
data section and a description section. The data section consists of a row for 
each ICD-9-CM or HCPCS code in the PCG. PCG Report 4 was produced 



The Development of a Physician Prospective Payment System for Ambulatory Care 21 



The Development of a Physician Prospective Payment System for Ambulatory Care 






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Final Report 



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PCG Analysis Reports 



• 



separately for medical PCGs and significant procedure PCGs. All diagnoses 
and procedures in a PCG are included in Report 4 for the calculation of totals. 

The data section of Report 4 consists of the following columns: 

1. SEQ A set of sequence numbers are assigned consecutively to each 
line in the report. Lines are numbered starting with the number 1 . 
These numbers are used to link the rows in this section of the report 
with a description of the significant procedure. 

2. HCPCS or DGNS The HCPCS or ICD-9-CM diagnosis code of the 
MSL. 

3. FREQUENCY The number of occurrences of the HCPCS or ICD-9- 
CM diagnosis code. 

Columns 4-14 provide a breakdown of the average allowed charge for the 
HCPCS or ICD-9-CM diagnosis code. 

4. TO_CH The average total allowed charges. 

5. PR_CH The average total allowed charges for the most significant 
line plus any incidental services (PCG 402 and 421). 

6. TC_CH The average total allowed charges for the technical compo- 
nent of the most significant line. 

7. EC_CH The average total allowed charge for ECG services (PCGs 70 
and 71). 

8. MR_CHG The average total allowed charge for a set of office services 
(PCGs 55, 56, 72, 94, 137, 171, 172, 239, 325, 330, 331, 332, and 
340). 

9. OL_CHG The average total allowed charge for a routine office labo- 
ratory services (PCGs 90, 91, 327, 356, 358, 362, 371, 372, 373, 374, 
375, 376, and 377). 

10. OR_CHG The average total allowed charge for office radiology 
(PCGs 74, 260, 273, 274, and 281). 

11. AN_CHG The average total allowed charge for anesthesia services 
(PCGs 335, 336, and 337). 

12. PH_ CH The average total allowed charge for pharmacy services 
(PCGs 391, 392, 393, 394, 395, and 396). 

13. MS_CHG The average total allowed charge for medical surgical sup- 
plies (PCGs 400, 401, and 403). 

14. OT_CH The average total allowed charges for other services not in 
columns 5 through 13. 

Columns 15-23 contain the percent of visits that have a specific service. 

15. TC_SV The percent of visits with a technical component. 

16. EC_SVC The percent of visits with an ECG (PCGs 70 and 71 ). 



The Development of a Physician Prospective Payment System for Ambulatory Care 23 



The Development of a Physician Prospective Payment System for Ambulatory Care 



17. MR_SV The percent of visits which include a minor office services 
(PCGs 55, 56, 72, 94, 137, 171, 172, 239, 325, 330, 331, 332, and 
340). 

18. OL_SV The percent of visits which include a routine laboratory ser- 
vices (PCGs 90, 91, 327, 356, 358, 362, 371, 372, 373, 374, 375, 376, 
and 377). 

19. OR_SV The percent of visits which include an office radiology servic- 
es (PCGs 74, 260, 273, 274, and 281). 

20. AN_SV The percent of visits which include an anesthesia service 
(PCGs 335, 336, and 337). 

21. PH_SV The percent of visits which include a pharmacy services 
(PCGs 391, 392, 393, 394, 395, and 396). 

22. MS_SV The percent of visits which include medical surgical supplies 
(PCG 400, 401, and 403). 

23. OT_SV The percent of visits which include services not specified in 
columns 15 through 22. 

At the bottom of PCG Report 4 is a detailed description of each HCPCS or 
ICD-9-CM code. The HCPCS or ICD-9-CM description in Report 4 is the 
same as PCG Report 1 for HCPCS codes and the same as PCG Report 2 for 
ICD-9-CM codes. 

Table 8 contains PCG Report 5 which examines a summary of professional 
data from PCG Reports 1-4 in conjunction with hospital outpatient facility 
cost data. The outpatient facility cost data used in PCG Report 5 is from the 
database used to develop APG version 2.0 (see Appendix A). PCG Report 5 is 
produced separately for significant procedure PCGs and for medical PCGs. 
PCG Report 5 consists of the following columns. 

1. HCPCS or DGNS The HCPCS or ICD-9-CM diagnosis code. 
Columns 2-6 refer to the hospital outpatient facility data. 

2. APG The version 2.0 APG to which the HCPCS or ICD-9-CM code was 
assigned. 

3. FREQ The number of occurrences in the hospital outpatient data of the 
HCPCS or ICD-9-CM codes. 

4. D_COST The average direct hospital outpatient facility cost. 

5. T_COST The average total hospital outpatient facility cost. 

6. Q The service class for HCPCS codes. 
Columns 7- 1 2 refer to the PCG professional data 

7. FREQ The number of occurrences in physician database. 

8. % OFF The percent of total occurrences of the HCPCS or ICD-9-CM 
code that occurred in the office. 

9. WRVU The average work RVU. 

10. TRVU The average total RVU. 



24 



Final Report 



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The Development of a Physician Prospective Payment System for Ambulatory Care 



25 



The Development of a Physician Prospective Payment System for Ambulatory Care 



11. AALOW The average allowed charge. 

12. ASUB The average submitted charge. 



13. LATEST Years for which the HCPCS or ICD-9-CM code is vaHd. 

14. DESCRIPTION Text description of the HCPCS or ICD-9-CM code. 
PCG reports 1-5 were used extensively in the development of PCGs. 

PCG Development Process 

APGs version 2.0 were used as a starting point for the development of PCGs. 
Version 2.0 APGs were assigned to the physician database and PCG Reports 
1-5 were produced. As PCGs were being developed, the PCG Reports allowed 
the following visit attributes to be taken into consideration. 

• Relative physician resources used as measured by RVUs, allowed charges 
and submitted charges 

• Site of service (e.g., office, emergency room, etc.) 

• Type of patient (e.g., new patient versus established patient) 

• Visit type (e.g., brief visit versus comprehensive visit) 

• Specialty of physician providing care 

• Type and frequency of services provided during the visit (e.g., medical/ 
surgical supplies, pharmaceuticals, etc.) 

• Relative facility resources used as measured by facility cost 

• Frequency of occurrence 

The process of developing the PCG definitions was highly iterative. As PCGs 
were defined, the summary statistics in the PCG analysis reports were 
recomputed and the PCG Reports were rerun and reviewed again. The process 
was repeated numerous times. The overall objective of the process was to 
have clinically similar groups of patients with similar professional and facihty 
resource use, but to achieve these objectives with as few PCGs as possible. 
Both professional resources and facility resources were taken into 
consideration. As a result, PCGs can be used not only as the basis of a 
physician payment system, but also as the basis of a payment system in which 
professional and facility payments are combined. In addition to resource use, 
the HCPCS procedure codes or ICD-9-CM diagnosis codes that comprise an 
individual PCG were selected taking into consideration the distribution of the 
site of service, type of patient and specialty of the physician. For example, to 
the extent possible, services that are primarily delivered in the ER were not 
included in the same PCG as services that were primarily delivered in the 
physician's office. Similarly, to the extent possible, the services that 
compromise a PCG were primarily delivered by physicians in the same or 
similar physician specialty. Final decisions on all PCG definitions were made 
in the following manner. 

Project medical staff reviewed the initial set of PCG definitions based on 
APGs. The PCG analysis reports were reviewed and potential PCG 



26 



Final Report 



PCG Development Process 



modifications identified. Potential PCG modifications that are clinically 
unreasonable often occur when reviewing statistical data on the average 
charges or cost of individual HCPCS procedure or ICD-9-CM diagnosis 
codes. 

• An individual code with a relatively low frequency of occurrence can 
sometimes appear to be in the wrong PCG based on historical data. 
Statistical results that had no clinical rationale were not used as the basis 
of PCG modifications. In general, potential PCG modificadons that were 
clinically unreasonable were not given further consideration as to their 
reassignment. However, if the procedure or diagnosis in question occurred 
with a high frequency, additional confirmation was obtained from experts 
in the specialty area. 

• If, in the judgement of the project medical staff, there was any possible 
clinical merit to a potential PCG modification, then the modification was 
reviewed with either the internal clinical consultants or outside experts in 
the specialty area of the modification. The purpose of the review was to 
provide additional clinical confirmation for PCG modifications. While 
this was not a formal consensus panel process, every attempt was made to 
have all PCG modifications clinically confirmed by outside experts. 

• All PCG modifications were developed in collaboration with the HCFA 
staff who were developing APCs. To the extent possible, the definitions of 
PCGs and APCs overlap. The overlap is primarily on the procedure PCGs 
where some of the PCGs and APCs are identical. However, the medical 
PCGs and APCs are substantially different. 

The end result of the development of PCGs was the creation of 402 PCGs plus 
9 error PCGs. Table 9 summarizes the number of PCGs by type of PCG. 



Type of PCG 


Number 


Significant procedure 


231 


Medical 


92 


Ancillary 


37 


Professional ancillary 


36 


Incidental 


6 


Error 


9 


Total 


411 



Table 9. Number to PCGs by type of PCG 

The major difference between version 2.0 of APGs and PCGs is the number of 
significant procedure groups. Version 2.0 of APGs has 126 significant 
procedure APGs, while there are 231 significant procedure PCGs. Dental 
procedures were not included in APGs. PCGs include 15 significant 
procedure PCGs for dental services. In general, the increase in the number of 
significant procedure PCGs reflects that physician resources are affected more 
significantly by the precise type of procedure than are facility costs. Appendix 
C contains a detailed description of the radonale for and nature of the 
differences between PCGs and APGs. Appendix D contains a complete list of 



The Development of a Physician Prospective Payment System for Ambulatory Care 



27 



The Development of a Physician Prospective Payment System for Ambulatory Care 



PCGs. Appendix E contains a mapping of each HCPCS code to a significant 
procedure, professional ancillary, ancillary, incidental or error PCG. 
Appendix F contains a mapping of each ICD-9-CM diagnosis code to a 
medical or error PCG. 



PCG Payment Simulation Overview 



The objective of the PCG payment simulation is to compute a PCG based 
payment amount for each visit and compare the PCG payment to historical 
charges for the visit. The simulations are performed on a budget neutral basis 
with total payments across all visits under the PCG system being equal to the 
total historical charges across all visits. The performance of the PCG payment 
model compared to historical charges is evaluated using the statistic R-. 
Multiple simulations were performed with alternative formulations of the 
PCG payment model (e.g., different methods of computing the PCG payment 
weights). Aggregate PCG payments for alternative formulations of the PCG 
payment model were also compared for specific subsets of visits (e.g., visits 
treated by physicians in a particular specialty). 

PCG weights were calculated using only those visits for which the MSL was 
either a significant procedure, medical visit, or professional ancillary. In 
addition, only those ancillary procedures included in the limited or extended 
set of ancillary PCGs were included in the calculation of PCG weights. Visits 
with only non professional ancillary services were not included in the 
payment simulations that reduced the number of visits in the payment 
simulations to 14,417,403. Weights were not computed for incidental PCGs in 
any of the models. For the purpose of calculating weights for visits with a 
single significant procedure, the MSL was used. If the visit had both 
professional and technical service classes for the same PCG present, the MSL 
referred to both lines. 

Five different bases for the payment weights were used. 

• Submitted charges for the MSL 

• Submitted charges for the MSL plus incidental, medical/surgical supplies 
and pharmacy submitted charges 

• Allowed charges for the MSL 

• Allowed charges for the MSL plus incidental, medical/surgical supplies 
and pharmacy allowed charges 

• RVUs 

Each of the five bases of weights were used to compute a payment weight for 
each PCG. Appendix G contains the five sets of PCG payment weights. 

When using submitted or allowed charges to compute PCG payment weights, 
extreme values of the submitted or allowed charges were encountered. In 
order to avoid having a few visits having a disproportionate impact on the 
weight for a PCG, the visits used to compute the PCG weights were trimmed. 
For each PCG the log of the submitted or allowed charge was computed for 



28 



Final Report 



■ ■**>•■ "^'A'iV*'*', 



PCG Payment Simulation Overview 



each visit and a trim point for each PCG was set at the mean plus three 
standard deviations above the log of the mean. All visits that exceeded the 
trim point were excluded from the computation of the PCG weights. Because 
visits that exceeded the trim point were considered of questionable validity, 
they were excluded from the computation of the weights. 

Once payment weights based on submitted charges or allowed charges were 
computed for each PCG, each payment weight was subdivided into three 
components (i.e., practice, work and malpractice). The RVU values for the 
HCPCS codes comprising the PCG were used to subdivide the PCG weights 
into the three components. The overall component breakdown for a PCG was 
computed by taking a weighted sum of the component breakdown of the 
HCPCS codes that comprised the PCG. The number of visits associated with 
each HCPCS code was used as the weighting factor in computing the 
weighted sum. For medical PCGs the component breakdown was based on 
E&M codes of the MSL. The end result was a payment weight for each PCG 
for each service class subdivided into three components. 

For a service delivered in the physician's office the payment weight for the 
visit is simply computed as the sum of the weights across the three 
components (i.e., work, practice and malpractice). However, if the service is 
not delivered in the physician office (e.g., a hospital ER), then the practice 
component of the weight is discounted (i.e., site of service discounting is 
applied to the physician bill). Thus, for a service delivered in a non office site, 
the weight for the visit is computed as the sum of the work weight plus the 
malpractice weight plus a discounted practice weight. Since the non office site 
discount factor currently used in the Medicare physician payment system is 50 
percent, the non office site discount factor used in the PCG payment 
simulations was also set at 50 percent. 

In addition to the site of service discount, a discount for multiple significant 
procedures was also applied. If more than one significant procedure PCG is 
present, then the PCG with the highest weight was given 100% of the weight 
and all other significant procedure PCGs were given 50% of their weight. The 
following exceptions were made in the application of the multiple significant 
procedure discount factor. If the highest weight PCG is either a professional 
or technical service class, the complementary service class of the same PCG 
was also given a weight of 100%. In addition to the complementary service 
classes of the same significant procedure PCG not being discounted, there 
was also a list of designated pairs of significant procedure PCGs that were not 
subject to multiple significant procedure discounting. These designated pairs 
of significant procedure PCGs represent distinct parts of a single procedure 
and the appropriate weight for the visit is the non discounted sum of the 
individual weights. For example, PCG 78, (injections for cardiac 
catheterization), is not discounted when it occurs in a visit with an MSL of 
PCG 76 (diagnostic cardiac catheterization), because PCG 78 and PCG 76 are 
integral parts of the same procedure. Appendix H contains a list of the 
designated pairs of significant procedure PCGs that are exempt from multiple 
significant procedure discounting. 



The Development of a Physician Prospective Payment System for Ambulatory Care 29 



The Development of a Physician Prospective Payment System for Ambulatory Care 



In a PCG payment system, each visit has a single weight computed for each 
PCG. Thus, a visit is described by a Ust of PCGs with each PCG having a 
weight associated with it. The same PCG that occurs multiple times may have 
a different weight for the same visit depending on the service class associated 
with the PCG. The overall weight for a visit is computed as the sum of the 
PCG weights with any applicable significant procedure or site of service 
discounting appUed. 

Not all services are covered by the PCG payment system. In general, ancillary 
services that do not usually involve physician effort or are not usually 
performed as a part of an office visit would not be paid using PCGs. As part of 
the PCG payment simulations, alternative lists of ancillary service to be 
included in the PCG payment system were tested. Table 10 contains a limited 
and extended list of ancillary PCGs. Ancillary PCGs which are not included 
in the limited or extended list of ancillary PCGs were excluded from all PCG 



Extended 


Limited 


PCG 


Descriptions 


X 


X 


38 


SPLINT. STRAPPING AND CAST REMOVAL 


X 


X 


39 


UNNA BOOT APPLICATION 


X 




55 


LEVEL I PULMONARY FUNCTION TESTS 


X 


X 


70 


SIMPLE ECG 


X 


X 


90 


LEVEL I VENIPUNCTURE AND BLOOD 
COLLECTION 


X 


X 


122 


SIMPLE ANOSCOPY 


X 




239 


REMOVAL OF IMPACTED CERUMEN AND 
FOREIGN BODIES 


X 




240 


AUDIOMETRY 


X 




281 


PLAIN FILM 


X 




325 


SIMPLE TUBE CHANGES AND INTRODUC- 
TIONS 


X 




350 


LEVEL I PATHOLOGY 


X 




356 


LEVEL I IMMUNOLOGY TESTS 


X 




358 


LEVEL I MICROBIOLOGY TESTS 


X 




360 


LEVEL I ENDOCRINOLOGY TESTS 


X 




362 


LEVEL I CHEMISTRY TESTS 


X 


X 


364 


BASIC CHEMISTRY TESTS 


X 




369 


LEVEL I CLOTTING TESTS 


X 




371 


LEVEL I HEMATOLOGY TESTS 


X 




373 


URINALYSIS 


X 


X 


374 


BLOOD AND URINE DIPSTICK TESTS 


X 


X 


375 


STREP TEST 


X 


X 


376 


HEMATOCRIT AND HEMOGLOBIN 


X 


X 


377 


GLUCOSE 



Table 10. Extended and Limited List of Ancillary PCGs 



30 



Final Report 



f.:;4*, i#«ii»|*' 



PCG Payment Simulation Overview 



payment simulations (i.e., the presence of these ancillary PCGs was ignored 
and had no impact on the results of the PCG payment simulations). 

The payment simulations were performed on a budget neutral basis. Thus, the 
factor that converts payment weights to dollars was established such that the 
total amount of money paid under PCGs was equal to the total charges (either 
submitted or allowed depending the prediction variable used in the payment 
simulation). The payment simulations compare historical visit charges to the 
PCG payment. A complete description of the computations and formulas in 
the PCG simulation is contained in Appendix I. 

Thirty different formulations of the PCG payment model were tested based on 
the following: 

• Three different basis for the payment weights: submitted charges, allowed 
charges and RVUs 

• The inclusion or exclusion of incidental costs including medical/surgical 
supplies and pharmacy charges in the PCG payment weight for a 
significant procedure and medical PCG 

• The extent to which ancillary services were paid under the PCG system: 
no ancillaries, limited ancillaries and extended ancillaries 

• Whether or not significant procedure discounting was applied 

Table 11 summarizes the 30 different formulations of the PCG payment 
model. The 30 formulations of the PCG payment model were compared by 
computing an overall coefficient of determination (R ) that provides a 
measure of the amount of variance in historical professional charges explained 
by the PCG payment system. The R^ values in Table 1 1 ranged from 0.7262 to 
0.8981. The R^ values for facility costs with APGs ranged from 0.701 to 
0.804 (see Appendix A). Thus, the R^ values for PCGs for professional cost 
are equivalent or slightly higher than the R^ values for APGs for facility cost. 
Similar results have been reported for the inpatient data in which the R~ for 

2 10 

DRG or inpatient professional fees is higher than the R for hospital costs . 
The R'^ values for PCGs are higher than the R values for DRGs for hospital 
costs (see Appendix A). 

Table 1 1 contains the R^ for both submitted charges and allowed charges. 
Across the different formulations of the PCG payment model the R for 
allowed charges is between 15 percent and 21 percent higher than for 
submitted charges. Since there is less variability in allowed charges, a higher 
R for allowed charges would be expected. 

In Table 1 1 when the basis of the payment weights was the same as the 
prediction variable, the R-^ was slightly higher Thus, for example, when 
submitted charges is the variable being predicted, the R^ is higher when 
submitted charge is the basis of the payment weights as opposed to allowed 
charges or RVUs. The difference in R^ due to differences in the basis of the 
payment weight is relatively small (less than 4 percent) with payment weights 
based on RVUs having the lowest R'^ values. 



The Development of a Physician Prospective Payment System for Ambulatory Care 31 



The Development of a Physician Prospective Payment System for Ambulatory Care 













Prediction Variable 


PCG 




Incidental 


Significant 


Ancillaries 






Payment 


Basis of 


Included 


Procedure 


Paid by 


Submitted 


Allowed 


Model 


Weights 


in Weights 


Discounting 


PCG 


Charges 


Charges 


1 


Submitted 


No 


No 


None 


0.7554 


0.8663 


2 


Submitted 


No 


No 


Limited 


0.7543 


0.8663 


3 
4 


Submitted 
Submitted 


No 
No 


No 


Extend 


0.7544 


0.8658 


Yes 


None 


0.7549 


0.8832 


5 ." 


Submitted 


No 


Yes 


Limited 


0.7548 


0.8832 


6 

7 


Submitted 
Submitted 


No 


Yes 


Extend 


0.7538 


0.8827 


Yes 


No 


None 


0.7552 


0.8658 


8 


Submitted 


Yes 


No 


Limited 


0.7551 


0.8658 


9 
10 


Submitted 
Submitted 


Yes 
Yes 


No 


Extend 


0.7542 


0.8653 


Yes 


None 


0.7549 


0.8830 


11 


Submitted 


Yes 


Yes 


Limited 


0.7548 


0.8830 


12 


Submitted 


Yes 


Yes 


Extend 


0.7438 


0.8825 
















13 


Allowed 


No 


No 


None 


0.7436 


0.8831 


14 


Allowed 


No 


No 


Limited 


0.7436 


0.8831 


15 
16 


Allowed 
Allowed 


No 
No 


No 


Extended 


0.7426 


0.8825 


Yes 


None 


0.7415 


0.8981 


17 


Allowed 


No 


Yes 


Limited 


0.7414 


0.8980 


18 
19 


Allowed 
Allowed 


No 


Yes 


Extend 


0.7405 


0.8974 


Yes 


No 


None 


0.7435 


0.8828 


20 


Allowed 


Yes 


No 


Limited 


0.7434 


0.8828 


21 

22 


Allowed 
Allowed 


Yes 
Yes 


No 


Extend 


0.7425 


0.8822 


Yes 


None 


0.7415 


0.8980 


23 


Allowed 


Yes 


Yes 


Limited 


0.7414 


0.8979 


24 


Allowed 


Yes 


Yes 


Extend 


0.7405 


0.8973 
















25 


RVU 


No 


No 


None 


0.7276 


0.8618 


26 


RVU 


No 


No 


Limited 


0.7275 


0.8617 


27 
28 


RVU 
RVU 


No 
No 


No 


Extend 


0.7262 


0.8608 


Yes 


None 


0.7294 


0.8818 


29 


RVU 


No 


Yes 


Limited 


0.7293 


0.8817 


M 


RVU 


No 


Yes 


Extend 


0.7276 


0.8805 


TaKlf! 


. -n d2 x_, < 




J Alt 1 <^l_ 









Payment Models 



32 



Final Report 



i*^ 



PCG Payment Simulation Overview 



The inclusion or exclusion of incidental costs in the payment weights had 
virtually no impact on the R~ values. Similarly, the inclusion of significant 
procedure discounting had only a slight impact on R^. For allowed charges, 
the addition of multiple significant discounting tended to increase R^ slightly 
(up to 2 percent). The inclusion of ancillaries in the PCG payment system had 
virtually no impact on R". 

In addition to computing an R , payment impact simulations were performed 
that assessed the payment impact of different formulations of the PCG 
payment model by region of the country, physician specialty, site of services 
and type of service. The intent of the payment impact simulations is to 
demonstrate the relative payment impact of different formulations of the PCG 
payment system. The payment simulations do not compare payment under a 
PCG payment system to current Medicare payments. For purpose of 
calculating and comparing the impact of the different PCG payment 
simulations, physician payments under each specific PCG system were equal 
to either total submitted or allowed charges. Thus, the simulations were 
performed on a budget neutral basis. The most basic of the 30 formulations of 
a PCG system was selected as the reference PCG system and the relative PCG 
payment impact was computed by comparing payments under each of the 
other PCG systems to the reference PCG system. The relative PCG payment 
impact was computed for different categories of geographic regions, 
physician specialty, site of service and type of service and was used to 
evaluate each component of the PCG system (e.g., multiple significant 
procedure discounting) in terms of its relative impact across the different 
categories. PCG payment model 1 was selected as the reference PCG payment 
model. PCG payment model 1 uses submitted charges as the basis of the 
payment weights, no incidental costs are included in the payment weights, no 
multiple significant procedure discounting is applied and no ancillary services 
are included in the payment simulations. Thus, PCG payment model 1 is the 
most basic PCG payment model. PCG payments under model 1 were 
compared to PCG payments under models 12, 13, 24, 25 and 30. Table 12 
summarizes the difference between these models. 

Models 1,13 and 25 are a basic PCG payment model with no incidental costs 
included in the payment weights, no multiple significant procedure discount 
and no ancillary services included. Models 1,13 and 25 only differ based on 
the basis of the payment weights (i.e., submitted charges, allowed charges and 





Payment Model 




1 


12 


13 


24 


25 


30 


Basis of Payment Weights 


Sub 
Chg 


Sub 
Chg 


Allow 
Chg 


Allow 
Chg 


RVU 


RVU 


Incidental Costs Included 


No 


Yes 


No 


Yes 


No 


No 


Significant Procedure Discounting 


No 


Yes 


No 


Yes 


No 


Yes 


Ancillaries Included 


No 


Yes 


No 


Yes 


No 


Yes 



Table 12. PCG Payment Impact Models 



The Development of a Physician Prospective Payment System for Ambulatory Care 



33 



The Development of a Physician Prospective Payment System for Ambulatory Care 



RVUs, respectively). Models 12, 24 and 30 include incidental costs in the 
payment weights, multiple significant procedure discounting and ancillary 
services. Like models 1,13 and 25, models 12, 24 and 25 only differ based on 
the basis of the payment weights (i.e., submitted charges, allowed charges and 
RVUs, respectively). PCG models 1, 13 and 25 will be referred to as basic 
PCG payment models while PCG models 12, 24 and 30 will be referred to as 
complete PCG payment models. 

The comparison of model I to models 12, 13, 24, 25 and 30 was performed 
separately with submitted charges and allowed charges as the prediction 
variable. Table 13 summarizes the results of the PCG payment impact 
sirfiulations. The payment impact of alternative PCG payment models was 
measured by taking the aggregate PCG payment to physicians in a category 
under the PCG model being evaluated, subtracting the aggregate PCG 
payments to physicians in the category under PCG model 1 and dividing the 
difference by the aggregate PCG payments to physicians in the category under 
PCG model 1. The formula for computing the PCG payment impact is 
contained in Appendix L. The result is the percent difference between 
physician payments under the PCG model being evaluated and physician 
payments under PCG model 1. An impact of +2.0 would indicate that the 
physician in the category would receive two percent more in aggregate 
payments under the PCG model being evaluated than the physicians would 
have under the basic PCG model (i.e., PCG model 1). The impact measures 
how the aggregate payments to physicians in each category would change as 
PCG model 1 is expanded (e.g., the addition of significant procedure 
discounting). Thus, the impact provides a means of evaluating the components 
of the PCG system in terms of its effect on aggregate PCG based payments to 
different categories. It does not provide a measure of the change in actual 
payments that physicians would receive under a PCG payment system. 

In the PCG payment simulations, no explicit adjustment for geographic 
practice cost differences was made. The reported allowed charges are adjusted 
using the Geographic Practice Cost Index which adjusts for market basket 
factors such as wage rate and rent. Thus, there was no need for an explicit 
geographic practice cost adjustment in the PCG payment simulations. 

In Table 13 the results are very similar when the prediction variable is 
submitted charges versus allowed charges. Therefore, only the results for 
submitted charges as the predication variable will be discussed. 

Geographic Region 

Based on the provider zip code, urban and rural locations were identified and 
subdivided into ten geographic regions. The unknown region contains visits 
for which the zip code was missing or invalid. Across the different 
formulations of the PCG payment model there was a modest difference in 
relative payment across urban and rural locations. Relative to the most basic 
PCG payment model (model 1), PCG payment models with the complete 
payment system or with allowed charges or RVUs as the basis of the payment 
weights tend to increase relative PCG payments to rural areas and decrease 

^ Final Report 



-i i«!!H( 



■'l'^ 



PCG Payment Simulation Overview 



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The Development of a Physician Prospective Payment System for Ambulatory Care 



35 



The Development of a Physician Prospective Payment System for Ambulatory Care 



relative PCG payments to urban areas. The most substantial change was 
associated with using the complete PCG payment model and using RVUs as 
the basis of the payment weights (model 30), in which there was a relative 
payment increase of 5.79 percent for rural areas and a 0.86 percent relative 
payment decrease for urban areas. 

Within rural or urban areas that relative payment impact across geographic 
regions is somewhat more substantial. While over all relative payments to 
urban areas decrease with the complete PCG payment system or with allowed 
charges or RVUs as the basis of the payment weights, across urban geographic 
regions the results vary. In general, urban locations in New England, Middle 
Atlantic, Pacific and other areas have relative PCG payment increases while 
the remaining urban locations have relative PCG payment decreases with the 
complete PCG payment system or with allowed charges or RVUs as the basis 
of the payment weights. For rural areas all geographic regions have payment 
increases with the complete PCG payment system or with allowed charges or 
RVUs as the basis of the payment weights. 

Physician Specialty 

Physician specialties were summarized into 12 broad physician specialty 
areas. Appendix B contains the mapping of individual physician specialties 
into the 12 broad physician specialty. The different formulations of the PCG 
payment model did have a substantial impact on relative payment across the 
physician specialties. In particular, the basis of the payment weights had a 
substantial impact. Relative to the most basic PCG payment model with 
payment weights based on submitted charges (model 1), the basic PCG 
payment model with payment weights based on allowed charges (model 13) 
tended to increase relative PCG payment for medical specialties and decrease 
relative payment for surgical and ancillary specialties. For psychiatry and 
psychology, primary care, oncology, obstetrics and gynecology and medical 
specialties the relative payment increases resulting from using allowed 
charges as the basis of payment weights is 19.41, 12.14, 1 1.18, 8.42, 3.78 and 
3.08 percent, respectively. While for anesthesiology, radiation therapy, 
radiology, other medical services and supplies, general surgery and surgical 
specialties the relative payment decrease is 36.72, 23.41, 21.17, 6.24, 5.12 and 
0.07 percent, respectively. If RVUs are used as the basis of the payment 
weights (model 25) relative payment impact shows the same pattern but the 
payment impact is magnified. For psychiatry and psychology, non-physician 
professional services, primary care, oncology, obstetrics and gynecology and 
medical specialties the relative payment increases resulting from using 
allowed charges as die basis of the payment weights is 33.76, 20.44, 18.42, 
15.1 1, 9.75 and 2.1 1 percent, respectively, while for anesthesiology, radiation 
therapy, radiology, other medical services and supplies, general surgery and 
surgical specialties the relative payment decrease is 36.09, 25.55, 23.66, 
14.30, 5.62 and 5.82 percent, respectively. Thus, relative to payment weights 
based on submitted charges, payment weights based on allowed charges or 
RVUs clearly increase payment for the medical specialties and decrease 
payment for the surgical and ancillary specialties. 



^ Final Report 



"A ■- ■-fe-;.<j«> 



PCG Payment Simulation Overview 



Relative to the most basic PCG payment model (model 1), a complete PCG 
payment model with payment weights based on submitted charges (model 12) 
also in general, results in a relative payment increase for medical specialties 
and a relative payment decrease for surgical specialties. However, the 
magnitude of the payment differences associated with the complete PCG 
payment model is much less than the payment differences associated with 
payment weights based on allowed charges and RVUs. The major departure 
from this pattern is that a change in the basis of the PCG payment weights 
from submitted charges to allowed charges or RVUs resulted in a relative 
payment increase for non-physician professional services (12.14 and 20.44 
percent for models 13 and 25, respectively). The change from the most basic 
PCG payment model (model 1 ) to the complete PCG payment model (model 
12) resulted in a relative payment decrease of 5.12 percent. 

For PCG payment models that include both the complete PCG payment model 
and payment weights based on allowed charges or RVUs (models 24 and 30) 
the magnitude of the relative payment increase for medical specialties and the 
relative payment decrease for surgical and ancillary specialties is magnified. 
For example, for the primary care specialty the relative payment increase 
resulting from the expansion to the complete PCG payment model (model 12) 
is 4.91 percent and the relative payment increase resulting from using RVUs 
as the basis of the payment weights (model 25) is 18.42 percent. The relative 
payment increase resulting from both the complete PCG payment model and 
the use of RVUs as the basis of the payment weights (model 30) is 23.24 
percent. Thus, for physician specialty, the impact of the complete PCG 
payment model and the basis of the payment weight have a relatively 
independent impact on the relative PCG payment. 



Site of Service 

The site of service was categorized into five sites: office, hospital outpatient 
department (OPD), emergency room, ambulatory surgery center and other. 
The different formulations of the PCG payment model had a substantial 
impact on relative payment across the sites of service. Relative to the most 
basic PCG payment model with weights based on submitted charges (model 
1), the basic PCG payment model with payment weights based on allowed 
charges (model 13) and RVUs (model 25) increased relative PCG payment for 
the office, ER and other sites 9.52, 7.08 and 12.95 percent for model 13 and 
14.07, 8.80 and 22.67 percent for model 25, respectively and decreased 
relative PCG payment for the OPD and ambulatory surgery centers 17.69 and 
12.15 percent for model 13 and 24.53 and 26.53 percent for model 25, 
respectively. 

Relative to the most basic PCG payment model (model 1), a complete PCG 
payment model with payment weight based on submitted charges (model 12) 
also results in a relative PCG payment increase for the office, ER and other 
sites (0.98, 4.03 and 2.33 percent, respectively) and a relative PCG payment 
decrease for the OPD and ambulatory surgery centers (1.66 and 3.49 percent, 
respectively). 



The Development of a Physician Prospective Payment System for Ambulatory Care 37 



The Development of a Physician Prospective Payment System for Ambulatory Care 



For PCG payment models that include both the complete PCG payment model 
and payment weights based on allowed charges or RVUs (models 24 and 30) 
the magnitude of the relative payment increase for the office, ER and other 
sites and the relative payment decrease for the OPD and ambulatory surgery 
centers is magnified. For example, for the emergency room, the relative 
payment increase resulting from the expansion to the complete PCG payment 
model (model 12) is 4.03 percent and the relative payment increase resulting 
from using RVUs as the basis of the payment weights (model 25) is 8.80 
percent. The relative payment increase resulting from both the complete PCG 
payment model and the use of RVUs as the basis of the payment weights 
(model 30) is 12.36 percent. Thus, for site of service, the complete PCG 
payment model and the basis of the payment weight have a relatively 
independent impact on the relative PCG payment. 

Type of Service 

The type of service was categorized into three types: significant procedure, 
medical and professional ancillary. The different formulations of the PCG 
payment model had a substantial impact on relative payment across the types 
of service. Relative to the most basic PCG payment model with weights based 
on submitted charges (model 1), the basic PCG payment model with payment 
weights based on allowed charges (model 13) and RVUs (model 25) increased 
relative PCG payment for medical services (14.45 percent for model 13 and 
23.69 percent for model 25, respectively) and decreased relative PCG 
payment for the significant procedure and professional ancillary services 
(7.09 and 14.21 percent for model 13 and 12.50 and 19.03 percent for model 
25, respectively). 

Relative to the most basic PCG payment model (model 1 ) a complete PCG 
payment model with payment weight based on submitted charges (model 12) 
results in a relative PCG payment increase for medical and professional 
ancillary services (5.83 and 4.26 percent, respectively) and a relative PCG 
payment decrease for significant procedures (3.99 percent). Thus, for 
professional ancillary services, there was a relative PCG payment increase 
associated with payment weights based on allowed charges or RVUs, but a 
relative PCG payment decrease associated with the complete PCG payment 
model. 

For PCG payment models that include both the complete PCG payment model 
and payment weights based on allowed charges or RVUs (models 24 and 30), 
the magnitude of the relative payment increase is relatively independent. For 
example, for professional ancillary services, the relative payment increase 
resulting from the expansion to the complete PCG payment model (model 12) 
is 4.36 percent and the relative payment decrease resulting from using RVUs 
as the basis of the payment weights (model 25) is 19.03 percent. The relative 
payment decrease resulting from both the complete PCG payment model and 
the use of the RVUs as the basis of the payment weights (model 30) is 15.38 
percent. Thus, for the type of service the impact of the complete PCG 



38 



Final Report 



.■A,y.;^.»,, »';'^»|*''- 



Discussion 



payment model and the basis of the payment weight have a relatively 
independent impact on the relative PCG payment. 



Discussion 

The statistical performance of PCGs in terms of R^ was evaluated for 30 
different formulations of the PCG payment model. The R^ results provide a 
measure of the extent to which simulated PCG payments for a patient 
correspond to the historical submitted or allowed charges for the patient. The 
statistical performance of PCGs is better than the statistical performance of 
both the inpatient DRGs and the outpatient APGs. The evaluation of the 
statistical performance of the 30 different PCG payment models resulted in 
the following conclusions. 

• PCGs have a higher R^ than both the APG and DRGs 

• PCGs have a higher R^ for allowed charges than for submitted charges 

• Alternative formulations of the PCG payment model do not differ 
substantially in terms of R 

The evaluation of the PCG payment impact simulations resulted in the 
following conclusions. 

• The basis of the payment weights is a critical factor in formulating a PCG 
payment system 

• Using payment weights based on allowed charges or RVUs as opposed to 
submitted charges 

- Increases relative PCG payments to medical specialties and decreases 
relative PCG payments to surgical and ancillary specialties 

- Increases relative PCG payments for physician services in the office, 
ER and other sites and decrease relative PCG payments for physician 
services in the OPD and ambulatory surgery centers 

- Increases relative PCG payments for medical services and decreases 
payment for significant procedures. 

Based on the above results, it is clear that weights based on submitted charges 
are substantively different from the weights based on allowed charges or 
RVUs. This result is analogous to the finding that APG weights based on 
submitted charges were substantively different from APG weights based on 
hospital outpatient costs (see Appendix A). Thus, PCG weights should not be 
based on submitted charges and should be based on either allowed charges or 
RVUs. The statistical performance (R^) of the complete PCG payment model 
(incidental costs included in the payment weights, multiple significant 
procedure discounting and ancillary services included) is similar to the 
statistical performance of the basic PCG payment model. However, the full 
PCG payment model does have a modest impact on aggregate payments 
across physician specialties, site of service and type of service. While the 
impact of the complete PCG payment model is not substantial, the complete 
PCG payment model is recommended for the following reasons: 



The Development of a Physician Prospective Payment System for Ambulatory Care 39 



The Development of a Physician Prospective Payment System for Ambulatory Care 



• The inclusion of the incidental cost in the payment weights and multiple 
significant discounting create more accurate payments that better reflect 
the physician cost and effort 

• Ancillaries typically performed in an office setting would be paid under 
the same payment system (i.e., PCGs) as other physician services, 
eliminating the administrative complexity of managing two methods of 
payment 

• There is virtually no additional administrative burden associated with the 
implementation of the complete PCG payment model as opposed to the 
basic PCG payment model. The major difference involves the 
computation of the PCG payment weights that would be performed 
centrally and would only need to be done on an annual basis. 

The PCG system differs from the current Medicare physicians payment 
system in several important ways. 

• The axis of classification of PCGs is the purpose of the visit and is 
specifically focused on as clear a definition as possible of the patient's 
problem(s). This is in contrast to the current E&M codes in which the axis 
of classification is physician work or effort. 

• The existing HCPCS coding system contains detailed distinctions on the 
technical aspects of individual procedures. Currently, separate payment 
levels are associated with each distinction. Like APGs, PCGs aggregate 
HCPCS codes for procedures into groups of HCPCS codes that have a 
similar therapeutic or diagnostic purpose and consume similar levels of 
resources. 

• The existing Medicare physician payment system pays distinct amounts 
for each ancillary service associated with a professional office visit. A 
PCG based physician payment system will include PCGs for each type of 
ancillary service. By aggregating the individual HCPCS codes associated 
with a type of ancillary service, the detailed distinctions in payment levels 
based on the precise technical aspects of the ancillary service are 
eliminated. Thus, for a particular kind of ancillary service, there is no 
financial incentive to perform the most technically involved type of that 
ancillary service. 

In summary, PCGs represent a substantial departure from the existing 
Medicare physician payment system. The recommended PCG system is the 
complete PCG payment model with payment weights computed based on 
either allowed charges or RVUs. 



Conclusions 



A visit-based PCG prospective payment system can provide an effective 
system for the payment of professional services across all ambulatory care 
settings. PCGs form a manageable, clinically meaningful set of patient classes 
that relate the attributes of patients to the amount and type of resources and 
effort required by physicians to provide care. PCGs are applicable to the full 



^ Final Report 



v*f-<«f 



f "**'!?» 



Conclusions 



range of ambulatory care settings including physician offices, hospital 
outpatient departments, hospital emergency rooms, ambulatory surgical 
centers, community mental health centers, comprehensive outpatient 
rehabilitation facilities, state or local public health facilities and rural health 
clinics. PCGs include the full scope of professional services including the 
direct physician services (i.e., performance of a procedure, establishing a 
diagnosis and patient counseling), technical services involving the use of 
specific equipment, interpretation of results and ancillary tests and services. 
The axis of classification of PCGs is the purpose of the visit and is specifically 
focused on as clear a definition as possible of the patient's problem(s). This is 
in contrast to the current Medicare physician payment system in which the 
axis of classification is physician work or effort. PCGs demonstrate better 
statistical performance than the DRGs or APGs. The components of the PCG 
system can be configured to achieve specific policy objectives and to provide 
financial incentives for physicians to dehver efficient care. Based on the 
statistical performance and relative PCG payment impact across the 
alternative formulations of the components of the PCG system, the complete 
PCG system with payment weights computed based on allowed charges or 
RVUs would be recommended for implementation. A PCG-based PPS for 
professional services can be a practical and effective basis for the reform of 
the Medicare physician payment system. 



The Development of a Physician Prospective Payment System for Ambulatory Care 41 



The Development of a Physician Prospective Payment System for Ambulatory Care 



References 

1 . Russell, L.: Medicare 's New Hospital Payment System. The Brookings 
Institution, Washington, DC. 1989. 

2. Kahn, K., Rubenstein, L., Draper, D. et al: The Effects of the DRG- 
Based Prospective Payment System on Quality of Care for Hospitahzed 
Medicare Patients. Journal of the American Medical Association 
264(1 5): 1953- 1997, October 17, 1990. 

3. Averill, R., Goldfield, N., Wynn, M., McGuire, T, Mullin, R., Gregg, L., 
Bender, J.: Design of a Prospective Payment Classification System for 

- Ambulatory Care, Health Care Financing Review, 1 993, 1 5( 1 ), 7 1 - 1 00. 

4. Vertrees, J., Pollatsek, J., Sheets, K., Stark, M.: Developing an Outpatient 
Prospective Payment System Based on APGs for the Iowa Medicaid Pro- 
gram, Journal of Ambulatory Care Management, 1 994, 1 7(4), 82-96. 

5. Rougham, J.: Blue Shield of California Outpatient Payment Program, 
Journal of Ambulatory Care Management, 1994, 2(3), 70-73. 

6. Federal Register. Medicare Program; Prospective Payment System for 
Hospital Outpatient Services; Proposed Rules 42 (409, et al) Vol. 63, No. 
173, 47551-48036. Office of the Federal Register, National Archives and 
Records Administration. Washington. U.S. Government Printing Office, 
September 8, 1998. 

7. Health Care Financing Administration, Medicare and Medicaid Statisti- 
cal Supplement 1997, Health Care Financing Review, 1997, 146-147. 

8. Hsiao, W.C, Braun, P., Yntema, D. et al.: Estimating Physician' Work 
for a Resource-Based-Relative -Value Scale, New England Journal of 
Medicine, 1998, 319(13), 835-41. 

9. American Medical Association: Current Procedural Terminology, 1999. 
Chicago. 1998. 

10. Mitchell, J., Ellis, R.: Alternative Payment Systems for Hospital Medical 
Staffs, Inquiry, Spring 1992, 29, 21-32. 



42 



Final Report 



Appendix A 



Description of APGs 



Design and Evaluation of a Prospective Payment System for Professional Services 43 



Development of a Prospective Payment System for Hospital-Based 

Outpatient Care 

Richard F. Averill, M.S., Norbert I. Goldfield, M.D., Laurence W. Gregg, B.S.,Thelma M. Grant, RRA 
Boris V. Shafir, B.S., Robert L. Mullln, M.D. 



The Ambulatory Patient Groups (APGs) 
are a patient classification system that 
was developed to be used as the basis of 
a prospective payment system (PPS) for 
the facility cost of outpatient care. This 
article will review the key characteristics of 
a patient classification system for 
ambulatory care, describe the APG 
development process, and describe a 
payment model based on the APGs. A 
PPS for outpatient care based on APGs 
requires numerous policy decisions to be 
made. The policy issues include the 
method of computing payment weights, 
the extent of ancillary packaging, the 
window of time for ancillary packaging, the 
extent of multiple procedure discounting 
and the outlier policy. Financial 
simulations of an APG based outpatient 
PPS were performed in order to evaluate 
the impact of alternative policy decisions. 
Recommendations are made relative to 
each policy issue and implementation 
issues are discussed. 



This report was prepared with the support of the Health Care Financing 
Administration, Office of Research and Demonstrations, under coopera- 
tive agreement No. 17-C-90057/5-01 to 3M Health Information Systems. 
Richard F. Averill, Nortjert I. Goldfield, Laurence W. Gregg, Thelma M. 
Grant and Boris V. Shafir are with 3M Health Information Systems, 100 
Barnes Road, Wallingford, CT 06492. For information on obtaining cop- 
ies of this document, contact: 3M Health Information Systems, 100 Bar- 
nes Road, Wallingford, CT 06492, 203-949-0303. The development of a 
prospective payment system for hospital-based outpatient care was per- 
formed in collaboration with the Health Care Financing Administration 
(HCFA). The staff of HCFA provided ongoing review and evaluation of the 
research: Mark Wynn (Team Leader), Joseph Cramer (Project Officer), 
Vivian Braxton, Patricia Brooks, William Goeller, Michael Hupfer, Mel Ing- 
ber, Barton McCann, Janet Wellham, Mark Krause, Carolyn Mullen, 
Cathaleen Ahem, James Mathews, and Marc Stone. In addition, this 
research involved the participation of many individual contributors: Jon 
Eisenhandler, James C. Vertrees, Gerard M. Doherty, Donn G. Duncan, 
and Bartara Steinbeck. A wide range of clinicians, hospital administra- 
tors, regulators, and researchers provided valuable input into the 
research. The opinions expressed are solely those of the authors and do 
not necessarily represent those of the Health Care Financing Administra- 
tion or 3M Health Information Systems. 



Introduction 

The OMNIBUS Budget Reconciliation 
Act (OBRA) of 1990 required the U.S. 
Health Care Financing Administration 
(HCFA) to design and evaluate a prospec- 
tive payment system (PPS) for the facility 
cost of outpatient care. OBRA called for 
the evaluation of a PPS for all hospital out- 
patient services (e.g., same-day surgery 
units, emergency departments, outpatient 
clinics, etc.). The facility cost refers to the 
hospital cost for providing care (e.g., room 
charges, medical and surgical supplies, 
etc.) and excludes the physician's profes- 
sional service. 

During the period 1988-1990, HCFA 
funded the development of Version 1 .0 of 
the Ambulatory Patient Groups (APGs) 
(Averill, Goldfield et al, 1994). The APGs 
are a patient classification system that 
was designed to be used as the basis of 
an outpatient PPS. Version 1.0 of the 
APGs was released in the spring of 1991. 
During the period 1991-1994, a number of 
payors, including state Medicaid agencies 
and Blue Cross and Blue Shield plans, 
began using APGs for outpatient payment 
(Vertrees, Pollatsek et al., 1994) Individual 
providers also began using APGs for inter- 
nal management. The availability of 
improved data, the expanding use of 
APGs and the potential use of APGs as 
the basis of a Medicare outpatient PPS 
resulted in HCFA funding the development 
of Version 2.0 of the APGs. One of the 
objectives of the development of Version 
2.0 was to simplify the APG system so that 
it could be more easily implemented as the 



44 



Final Report 



■■V-':-^t 



Description of APGs 



basis of a Medicare outpatient PPS. 

The research project to develop Version 
2.0 of the APGs was initiated in 1 992. The 
development of Version 2.0 of the APGs 
was performed by 3M Health Information 
Systems in close cooperation with HCFA. 
Version 2.0 of the APGs was completed 
and released in August 1995 (Goldfield, 
Averill, et al., 1997). 

In March 1995, HCFA submitted a 
Report to the U.S. Congress recommend- 
ing that the APGs or an APG-like patient 
classification system, be used as the basis 
of a Medicare Outpatient PPS. In August 
1997, the U.S. Congress passed the Bal- 
anced Budget Act of 1997 which included 
the requirement that a Medicare Outpa- 
tient PPS be implemented beginning in 
January 1999. 

This article will discuss the development 
of the APG patient classification system 
and its use in an outpatient PPS. Financial 
simulations of an APG-based PPS are 
presented and various policy alternatives 
are evaluated. 

Characteristics of an Outpatient Patient 
Classification System 

Fundamental to the design of any Pro- 
spective Payment System (PPS) for 
ambulatory care is the selection of the 
basic unit of payment. The Medicare inpa- 
tient PPS uses the hospital admission as 
the basic unit of payment. The basic unit 
for ambulatory care is the visit, which rep- 
resents a contact between the patient and 
a health care professional. The visit could 
be for a procedure, a medical evaluation, 
or an ancillary service such as a chest x- 
ray. For each type of visit a prospective 
price could be established that includes all 
routine services (e.g., blood tests, chest x- 
rays, etc.). If the cost of the routine ser- 
vices rendered during a visit were included 
in the payment for the visit, hospitals 



would have the financial incentive to con- 
trol the amount of services rendered. 

An ambulatory patient classification sys- 
tem serves the same function as the Diag- 
nosis Related Groups (DRGs) in the 
Medicare inpatient PPS. The patient clas- 
sification system provides the basic prod- 
uct definition for the ambulatory setting 
and will have important secondary effects. 
For example, DRGs have brought about 
fundamental changes in management, 
communications, cost accounting and 
planning within hospitals. These changes 
have resulted in improved efficiency in the 
delivery of inpatient care. The benefits to 
hospital management that resulted from 
the adoption of DRGs would also be 
expected to occur in the ambulatory set- 
ting. Thus, the selection of an appropriate 
patient classification system is critical to 
the success of an outpatient PPS. An 
ambulatory patient classification system 
should have the following characteristics. 

Comprehensiveness 

The patient classification system must 
be able to describe every type of patient 
seen in an ambulatory setting. This 
includes medical patients, patients under- 
going a procedure and patients who 
receive ancillary services only. 

Administrative Simplicity 

The patient classification system should 
be administratively straightfon/vard to 
implement. The number of patient classes 
should be kept to a reasonable number. A 
patient classification system containing 
relatively few patient classes (e.g., fewer 
than the number of DRGs) will be more 
easily understood by providers and will 
ease the administrative burden on both 
facilities and payors. In addition, the data 
used to define the patient classes should 
be compatible with existing billing, data 
collection, coding, storage and processing 



The Development of a Physician Prospective Payment System for Ambulatory Care 



45 



Appendix A 



practices. Such compatibility will decrease 
implementation costs, data errors and 
other administrative problems. 

Homogeneous Resource Use 

The amount and type of resources (e.g., 
operating room time, medical surgical sup- 
plies, etc.) used to treat patients in each 
patient class should be homogeneous. If 
resources used vary widely within a 
patient class, it would be difficult to 
develop equitable payment rates. If a facil- 
ity treated a disproportionate share of 
either the expensive or inexpensive cases 
within a patient class, then the aggregate 
payments to that facility might not be 
appropriate. Further, the facility might be 
encouraged to treat only the less costly 
patients within the patient class causing a 
potential access problem for the complex 
cases. Thus, a homogeneous pattern of 
resource use is a critical characteristic of 
any patient classification system used in a 
PPS. 

Clinical Meaningfulness 

The definition of each patient class 
should be clinically meaningful. For exam- 
ple, a patient class involving a procedure 
should, in general, contain only proce- 
dures on the same body system, which 
are of the same degree of extensiveness 
and which utilize the same method (e.g., 
surgical, endoscopic, percutaneous, etc.). 
The underlying assumption in a PPS is 
that hospitals will respond to the financial 
incentives in the system and become 
more efficient. Clinical meaningfulness is 
critical because in order to respond effec- 
tively, hospitals must communicate the 
incentives to their medical staffs. A clini- 
cally meaningful patient classification sys- 
tem will be more readily accepted by 
providers and will be more useful as a 
communication and management tool. 



Minimal Upcoding and Code 
Fragmentation 

In the patient classification system, 
there should be minimal opportunities for 
providers to assign a patient to a higher 
paying class through upcoding. A patient 
classification system with many classes 
that are based on subtle distinctions is 
susceptible to upcoding. In general, the 
patient classes should be as broad and 
inclusive as possible without sacrificing 
resource homogeneity or clinical meaning- 
fulness. In addition, there should be mini- 
mal opportunities for increasing payment 
by separately reporting the constituent 
parts of a procedure. 

Flexibility 

In a visit based payment system, there 
is a wide array of options in terms of which 
ancillary services should be included in 
the visit payment. The extent to which 
ancillary services are included in the visit 
payment is a policy decision. The patient 
classification system must be flexible 
enough to accommodate a full range of 
options for incorporating ancillary services 
into the visit payment. In addition, the 
patient classification system should be 
structured to allow changes in technology 
and practice pattems to be easily incorpo- 
rated. This system should provide a flexi- 
ble framework that can adapt to such 
change without requiring a major restruc- 
turing of the classification system. 

Because of the fundamental role that the 
patient classification system plays in a 
PPS, it is essential that the patient classifi- 
cation system possess substantially all of 
the above characteristics. 

Overview of APGs 

APGs are designed to explain the 
amount and type of resources used in an 
ambulatory visit. Ambulatory resources 



Final Report 



Description of APGs 



include pharmaceuticals, supplies, ancil- 
lary tests, type of equipment needed, type 
of room needed, treatment time, etc. 
Patients in each APG have similar clinical 
characteristics, resource use, and costs. 
Similar resource use means that the 
resources used are relatively constant 
across all patients within each APG. How- 
ever, some variation in resource use will 
remain among the patients in each APG. 
In other words, the definition of the APG is 
not so specific that every patient included 
in the same APG is identical, but rather 
the level of variation in patient resource 
use is known and predictable. Thus, 
although the precise resource use of a 
particular patient cannot be predicted by 
knowing the APG of the patient, the aver- 
age pattern of resource use of a group of 
patients in an APG can be accurately pre- 
dicted. 

Patients in each APG also have similar 
clinical characteristics. Similar clinical 
characteristics mean that the patient char- 
acteristics included in the definition of the 
APG should relate to a common organ 
system or etiology and that a specific med- 
ical specialty should typically provide care 
to the patients in the APG. In addition, all 
available patient characteristics that con- 
sistently affect resource use should be 
included in the definition of the APGs. For 
example, patients with diabetes may or 
may not have ketoacidosis. Although 
these patients are the same from organ 
system, etiology and medical specialist 
perspectives, the APGs will assign these 
patients to different patient classes, 
because the presence of ketoacidosis 
consistently increases the resource use of 
diabetic patients. On the other hand, sets 
of unrelated surgical procedures should 
not be used to define an APG because 
there is no medical rationale to substanti- 
ate that resource use would be expected 
to be similar. 



The definition of similar clinical charac- 
teristics is, of course, dependent on the 
goal of the classification system. For 
APGs, the definition of clinical similarity 
relates to the medical rationale for differ- 
ences in resource use. If, on the other 
hand, the classification goal was related to 
patient prognosis, then the definition of 
patient characteristics that were clinically 
similar might be different. The requirement 
that APGs be clinically homogeneous 
caused more patient classes to be formed 
than is necessary for explaining resource 
use alone. For example, patients with a 
dilation and curettage or a simple hemor- 
rhoid procedure are quite similar in terms 
of most measures of resource use. How- 
ever, different organ systems and different 
medical specialties are involved. Thus, the 
requirement that APGs have similar clini- 
cal characteristics precludes the possibility 
of these types of patients being in the 
same APG. 

APGs were developed to encompass 
the full range of ambulatory settings 
including same day surgery units, hospital 
emergency rooms, and outpatient clinics. 
APGs, however, do not address phone 
contacts, home visits, nursing home ser- 
vices or inpatient services. Data from sev- 
eral sources, including hospital outpatient 
departments and ambulatory surgical cen- 
ters, were used in developing the APGs. 
However, better cost data from nonhospi- 
tal sites are needed in order to determine 
if there are any problems with applying 
APGs to nonhospital sites. 

Although the anticipated initial applica- 
tion of APGs focuses on Medicare 
patients, APGs were developed to repre- 
sent ambulatory patients across the entire 
patient population. For example, APGs 
relating to pregnancy were developed 
even though pregnancy is not often 
encountered in the Medicare population. 



The Development of a Physician Prospective Payment System for Ambulatory Care 



47 



Appendix A 



APGs were developed to differentiate 
facility costs and not professional costs. 
However, professional costs relate prima- 
rily to professional time and, therefore, 
directly relate to facility time. Professional 
time can serve as a proxy for the amount 
of time a patient used the resources of the 
facility. During the development of APGs, 
facility costs such as supplies and equip- 
ment as well as professional time were 
taken into consideration. 

The data elements used to define APGs 
were limited to the information routinely 
collected on the Medicare claim fomn and 
consisted of the diagnoses coded in Inter- 
national Classification of Diagnoses 9th 
Revision Clinical Modifications (ICD-9- 
CM) and procedures coded in Current 
Procedural Terminology Fourth Edition 
(CPT-4). The patient characteristics used 
in the definition of the APGs were 
restricted to those readily available in 
order to insure that the APGs could be 
readily implemented. 

Selection of the initial Classification 
Variable 

The first step in developing a patient 
classification system is to choose the ini- 
tial classification variable. In the DRGs, 
the principal diagnosis is used to classify 
patients into a set of mutually exclusive 
Major Diagnostic Categories (MDCs). 
Within each MDC, procedure, age and 
complication and comorbidities are used 
to complete the DRG classification sys- 
tem. APGs use procedure instead of diag- 
nosis as the initial classification variable. 
The decision to do so was based on the 
following considerations: 

• When a significant procedure is per- 
formed in an ambulatory setting, it is 
normally the reason for the visit. The 
procedure will normally be scheduled in 
advance and will consume the vast 



majority of resources associated with 
the visit. 

• With procedure as the initial classifica- 
tion variable, each procedure will be 
assigned to only one APG. With princi- 
pal diagnosis as the initial classification 
variable, the same procedure could be 
assigned to many different APGs 
depending on the principal diagnosis. 
Having each procedure in only one APG 
also reduces the number of APGs and 
simplifies the establishment of prospec- 
tive prices. 

Once the decision to use procedure as 
the initial classification variable was made, 
it was then necessary to partition all proce- 
dures into a set of mutually exclusive and 
exhaustive procedure groups. The first 
step in the process was to identify all pro- 
cedures that could be done only on an 
inpatient basis. An inpatient procedure 
was defined as a procedure that requires 
at least 24 hours of post operative recov- 
ery time or monitoring before a patient can 
be safely discharged. Some procedures, 
such as craniotomies, are clearly inpatient 
procedures. However, there are other pro- 
cedures such as the treatment of an open 
fracture that are nomnally done on an inpa- 
tient basis but can sometimes be done on 
an ambulatory basis. Further, patients with 
the same CPT-4 procedure code can have 
a great deal of variation in the complexity 
of the procedure performed. For example, 
the treatment of an open humeral fracture 
can vary considerably in complexity. 

Only the simplest cases of procedures 
normally done on an inpatient basis are 
done on an ambulatory basis. Thus, an 
open humeral fracture treated on an 
ambulatory basis will have minimal bone 
displacement and tissue damage. Such 
procedures are included in the APG pro- 
cedure classification. When grouping pro- 
cedures together to form homogeneous 



48 



Final Report 



(^■t 



Description of APGs 



« 



subclasses, it is important to recognize tlie 
variations of severity witliin a CPT-4 code 
and that only the simplest cases of com- 
plex procedures are treated in an ambula- 
tory setting. 

The procedures which could be per- 
formed on an ambulatory basis were then 
assigned to one of the following two 
classes: 

Significant Procedure 

This is a procedure that is normally 
scheduled, constitutes the reason for the 
visit and dominates the time and 
resources expended during the visit, (e.g., 
the excision of a skin lesion). Significant 
procedures range in scope from debride- 
ment of nails to pacemaker replacements 
as well as significant tests, such as a 
stress test. 

Ancillary Sen/ices 

The term ancillary services is used to 
refer to both ancillary tests and ancillary 
procedures. An ancillary test is one that is 
ordered by the primary physician to assist 
in patient diagnosis or treatment. Radiol- 
ogy, laboratory and pathology constitute 
ancillary tests. An ancillary procedure is a 
procedure that increases but does not 
dominate the time and resources 
expended during a visit, Examples of 
ancillary procedures are immunizations, or 
the insertion of an intrauterine device 
(lUD). 

Only patients with a significant proce- 
dure were assigned to significant proce- 
dure APGs. All medical services provided 
to the patient were assumed to be an inte- 
gral part of the procedure. Patients who 
received medical treatment but who had 
no significant procedures performed were 
assigned to Medical APGs. Examples of 
medical treatments which do not involve a 
significant procedure include treatment for 
poisoning, neonatal care, and well care. 



Visit 




Figure 1 Initial APG Partition Based on the 
Presence of a Significant Procedure 

Figure 1 illustrates the APG partition 
based on services rendered or procedures 
performed. Patients who undergo a signifi- 
cant procedure are assigned to a signifi- 
cant procedure APG. For example, a 
patient who had a simple skin excision 
performed to remove a skin lesion would 
be placed in a significant procedure APG 
based on the CPT-4 code which describes 
the precise procedure. Patients receiving 
medical treatment which does not involve 
a significant procedure, were assigned to 
medical APGs. A patient who visited a 
physician to have a skin lesion evaluated 
and had no significant procedures per- 
formed would be assigned to a medical 
APG based on the ICD-9-CM diagnosis 
code. A patient who neither received med- 
ical treatment nor underwent a significant 
procedure, but had an ancillary service 
performed would be assigned to only an 
ancillary service APG. 

Development of Significant Procedure 
APGs 

Significant ambulatory procedures are 
subdivided into groups of CPT-4 codes 
based on the body system associated with 
the procedure: 

• Integumentary System 

• Musculoskeletal System 



The Development of a Physician Prospective Payment System for Ambulatory Care 



49 



Appendix A 



• Respiratory System 

• Cardiovascular System 

• Hematologic, Lymphatic and Endocrine 

• Digestive 

• Urinary System 

• Male Genital System 

• Female Genital System 

• Nervous System 

• Eye and Ocular Adnexa 

• Facial, Ear, Nose, Mouth and Throat 

• Therapeutic and Other Significant 
Radiological Procedures 

• Physical Medicine and Rehabilitation 

• Mental Illness and Substance Abuse 
Therapies 

Body systems were formed as the first 
step toward ensuring that the procedures 
in each APG were clinically similar. The 
significant procedures in each body sys- 
tem generally correspond to a single 
organ system and are associated with a 
particular medical specialty. The body sys- 
tems used in the procedure APGs are sim- 
ilar to the Major Diagnostic Categories 
(MDCs) for the DRGs. However, there are 
some significant differences. For example, 
the body system for skin and subcutane- 
ous tissue includes muscle, whereas mus- 
cle is in the musculoskeletal MDC. Muscle 
was included in the skin and subcutane- 
ous tissue body system because most 
procedures involving the fascia (connec- 
tive tissue) are clinically similar to dermal 
procedures and have similar pattems of 
resource use. If fascia or muscle proce- 
dures were included within the bone and 
joint body system then it would have been 
necessary to form separate APGs for 
muscle procedures. Thus, the inclusion of 
muscle in the skin and subcutaneous tis- 
sue body system reduced the overall num- 
ber of APGs. Further, there are MDCs for 
etiologies such as infectious diseases, for 
which there are no corresponding body 
system in the significant procedure APGs. 



Some body systems had few proce- 
dures performed on an ambulatory basis. 
For example, except for biopsies or exci- 
sions of the thyroid, there are no endo- 
crine procedures performed on an 
ambulatory basis. Thyroid procedures 
were included with lymph node biopsies 
and excisions because they are clinically 
quite similar. 

Once each significant procedure was 
assigned to a body system, the proce- 
dures in each body system were subdi- 
vided into clinically similar classes. The 
classification variables considered in the 
formation of the procedure classes are 
shown in Table 1 . In general, method was 
used as the primary classification variable. 
Different methods such as surgery, endos- 
copy manipulation, dilation, catheteriza- 
tion, laser and needle often require 
different types of rooms, equipment and 
supplies as well as different amounts of 
time. For example, procedures in the res- 
piratory body system were initially divided 
by method into endoscopic, needle or 
catheter and noninvasive test subgroups. 
On the other hand, most male reproduc- 
tive procedures are surgical; therefore, the 
male reproductive body system was ini- 
tially subdivided on site and not method. 
Surgical procedures were usually subdi- 
vided based on type (i.e., incision, exci- 
sion, or repair). The time required to 
perform a procedure depends on the type 
of procedure, with repairs generally taking 
the most time. Thus, surgical skin proce- 
dures were divided into separate incision, 
excision and repair groups. Endoscopic 
procedures were often divided into sepa- 
rate classes depending on purpose (i.e., 
diagnostic or therapeutic). Therapeutic 
endoscopic procedures generally require 
more time. The extent of a procedure was 
often taken into consideration. Thus, skin 
excisions of 2 cm and 20 cm are assigned 
to different APGs. 



50 



Final Report 



■'•'"■'i-'^",' 



Description of APGs 



Variable 


Example 


Site 


Face, Hand, etc. 


Extent 


Excision Size: 2 cm Versus 20 cm 


Purpose 


Diagnostic or Therapeutic 


Type 


Incision, Excision or Repair 


Method 


Surgical, Endoscopic, etc. 


Device 


Insertion or Removal 


Medical Specialty 


Urology, Gynecology, etc. 


Complexity 


Time Needed to Perfomn Procedure 



Table 1 Classification Variables Considered in the 
Development of the Significant Procedure APGs 

Another aspect of extent is the complex- 
ity of the procedure. Complexity basically 
refers to the amount of time normally 
required to perform a procedure. For 
example, the excision of a pressure ulcer 
will generally require more time than the 
excision of a skin lesion. Thus, the exci- 
sion of the pressure ulcer was viewed as 
more complex, and therefore, assigned to 
a different APG. Anatomical site (e.g., 
face, hand, etc.) within a body system was 
used in order to ensure clinical similarity 
(e.g., procedures of the external ear ver- 
sus the internal ear), and was also used to 
implicitly reflect complexity (e.g., treatment 
of a closed fracture of a finger is usually 
less complex than treatment of a closed 
fracture of other sites). 

If a procedure involved the insertion of a 
device (e.g., neurostimulator), then a sep- 
arate APG was formed in order to recog- 
nize the cost of the device. Medical 
specialty was never explicitly used in the 
significant procedure APG formation, but 
procedures normally done by different 
medical specialties were usually put in dif- 
ferent APGs. 

Development of Medical APGs 

Medical APGs describe patients who 
receive medical treatment but do not have 
a significant procedure performed during 
the visit. The fact that a patient had a spe- 
cific significant procedure performed pro- 



vides a great deal of precise information 
regarding the amount and type of 
resources typically used during the visit. 
Patients without a significant procedure 
(i.e., medical patients) can use a wide 
range of resources depending on the con- 
dition of the patient at the time of the visit. 
Medical patients can be described using 
the diagnoses of the patient coded in ICD- 
9-CM which allows both specific diseases 
(e.g., pneumonia) as well as signs, symp- 
toms and findings (SSFs) (e.g., chest pain, 
melena, elevated sedimentation rate, etc.) 
to be coded. The term "diagnosis" will be 
used to refer generically to SSFs and dis- 
eases. The standard Medicare claims form 
and the ICD-9-CM ambulatory coding 
guidelines require that the diagnosis that 
was the primary reason for the visit be 
indicated. Further, any additional diag- 
noses that are present may be listed on 
the claim as secondary diagnoses. The 
primary variable used to form the medical 
APGs is the diagnosis coded as the rea- 
son for the visit. The reason for the visit is 
the primary determinant of the resources 
used (e.g., time, tests ordered, etc.) during 
the visit. Thus, the medical APGs are 
based on the type of patient being treated. 

The treatment of a medical patient is 
often highly influenced by the SSFs 
present at the time of the visit. In general, 
the coding of a disease simply indicates 
that the disease was present but gives no 
indication of how extensive or severe the 
disease was at the time of the visit. The 
coding of SSFs in addition to the underly- 
ing disease provides some indication of 
the extensiveness of the disease. The use 
of SSFs in the definition of the medical 
APGs was difficult because of the follow- 
ing limitations in the ICD-9-CM codes for 
SSFs: 

• Many of the ICD-9-CM codes for SSFs 
are not precise. For example, abdominal 



The Development of a Physician Prospective Payment System for Ambulatory Care 



51 



Appendix A 



rigidity (code 7894) lias no precise clini- 
cal definition. 
• There are a large number of SSF codes 
that refer to abnormal laboratory results 
that are imprecise. For example, a diag- 
nosis of hypokalemia does not convey 
useful information because the range of 
potassium levels associated with 
hypokalemia can vary significantly in 
terms of clinical significance. 

In addition. to the imprecision of many of 
the SSF codes, the use of SSFs as a pri- 
mary variable in the medical APGs could 
create opportunities for upcoding. If the 
APGs for SSFs had a high payment 
weight then there would be a financial 
motivation to code the SSFs instead of the 
underlying disease. The fact that the ICD- 
9-CM coding rules allow only nonroutine 
SSFs to be coded also limited the applica- 
bility of SSFs in the definition of the medi- 
cal APGs. As a result of the problems 
associated with SSFs, the SSFs used in 
the definition of the medical APGs were 
restricted to SSFs with the following char- 
acteristics: 



a relatively precise clinical 



• SSFs with 
meaning 

• SSFs that were significant enough not to 
be a routine part of most diseases 

• SSFs that were significant enough to 
tend to dominate the resources used 
during the visit. Thus, upcoding is not an 
issue because assignment to the SSF 
APG is appropriate irrespective of the 
underlying disease. 

A single major SSF APG for medical 
patients was formed. Examples of SSFs 
included in the major SSF APG are men- 
ingismus and gangrene. In addition to the 
SSF codes, there were also ICD-9-GM 
codes included in the major SSF APG that 
specify both the underiying disease and 
the SSF (e.g., diabetic ketoacidosis). A 
patient is assigned to the major SSF APG 



whether the major SSF is coded as the 
reason for the visit or as a secondary diag- 
nosis. The major SSF APG identifies the 
medical patients with extensive diseases 
who are usually treated in emergency 
rooms and who require significant 
amounts of resources. Patients who have 
non-major SSFs coded as the reason for 
the visit, are assigned to the medical APG 
that is usually associated with the SSF 
(e.g., cough is assigned to the upper respi- 
ratory infection APG). 

After patients who had a major SSF 
were assigned to a separate APG, the 
medical APGs were formed on the basis of 
the ICD-9-GM diagnosis code that was the 
reason for the visit. Thus, all possible ICD- 
9-CM diagnoses were divided into a set of 
mutually exclusive and clinically similar 
classes. The classification variables con- 
sidered in the fonnation of the medical 
classes are shown in Table 2. 



Variable 



Example 



Etiology 
Body System 
Type of Disease 
Medical Specialty 
Patient Age 
Patient Type 
Complexity 



Trauma, Malignancy, etc. 

Respiratory, Digestive, etc. 

Acute or Chronic 

Ophthalmology, Gynecology, etc. 

Pediatric, Adult, etc. 

New or Old 

Time Needed to Treat the Patient 



Table 2: Classification Variables Considered in the 
Development of the Medical APGs 

The initial variable used to form the 
medical APGs was the etiology of the 
diagnosis that was the reason for the visit: 

• Well Care & Administrative • Malignancy 

• Trauma • Poisoning 

• Infections • Neonate 

• Pregnancy • other 

As a first step in the formulation of the 
medical APGs, each ICD-9-CM diagnosis 
code was assigned to one of the etiology 
subgroups. Malignancies and trauma were 
assigned to separate subgroups because 



52 



Final Report 



.«• 



>:••' ■-•JSf-'* ■ 



Description of APGs 



they had unique resources associated with 
the care provided (e.g., frequent radiology 
and laboratory services). The body system 
group encompasses a broad spectrum of 
diseases from acute diseases such as 
pneumonia to chronic diseases such as 
hypertension. The "other" group was then 
divided into subgroups based on the spe- 
cific body system of the diagnosis that was 
the reason for the visit: 

Malignancy 

Poisoning 

Trauma 

Neonate 

Pregnancy 

Infectious Diseases 

Nervous System Diseases 

Eye Diseases 

Ear, Nose, Mouth and Throat Diseases 

Respiratory System Diseases 

Cardiovascular System Diseases 

Digestive System Diseases 

Major Signs, Symptoms and Findings 

Musculoskeletal Diseases 



• Skin and Breast Diseases 

• Endocrine, Nutritional and Metabolic 
Diseases 

• Kidney and Unnary Tract Diseases 

• Male Genital System Diseases 

• Female Genital System Diseases 

• Immunologic and Hematologic Diseases 

The initial subdivision of the medical 
APGs is shown in Figure 2. Once all the 
subclasses based on the etiology and the 
body system were formed, then the other 
classification variables in Table 2 were 
used to further subdivide each etiology 
and body system. 

Whether a diagnosis was acute or 
chronic was not explicitly used in the for- 
mation of the medical APGs. There are 
medical APGs that contain only diagnoses 
that are acute or chronic, but a medical 
APG was never formed for the explicit pur- 
pose of identifying acute or chronic dis- 
eases. Medical specialty was never 
explicitly used in the medical APG forma- 
tion, but diseases normally treated by dif- 













\ Nervous 
Urinary 




Medical Patients 








1 


\ 






f Major 
V SSF 




APG 


^>-.,,.Other 

\ ^~~~~~---.^ 

Poisoning ^~--. 

reg nancy 

Respiratory '^^^ 
Skin 




Well Care and ^< 
Administrative -^ 

Infection -^ 

Malignan 


Etiology 
"^ ^^^^^ p 

Frauma ^., 

Newb< 


C 


Body ^\ 
Systenri^ 

Digestive 



Figure 2 Initial Medical APG Logic 



The Development of a Physician Prospective Payment System for Ambulatory Care 



53 



Appendix A 



ferent medical specialties were usually put 
in different APGs. Age was not used in the 
definition of medical APGs. 

Whether a patient was a new patient or 
an old patient was considered as a possi- 
ble variable in the formation of the medical 
APGs. However, the new patient old 
patient distinction was not used for the fol- 
lowing reasons: 

• There is difficulty in establishing a pre- 
cise definition of a new patient. New can 
refer to either the physician or the facil- 
ity. Thus, a patient may be considered 
new only the first time the patient is 
treated as an outpatient at the hospital. 
Alternatively, the patient may be consid- 
ered new for each visit in which the 
patient is treated by a different physi- 
cian. From a resource use perspective, 
the presence of new diagnoses or prob- 
lems is often just as important as 
whether the patient is new to the facility 
or physician. The only definition of new 
that is not prone to upcoding is new to 
the facility. 

• The impact on resources of whether a 
patient is a new patient varies by setting. 
For emergency room and same-day sur- 
gery units, the fact that the patient is 
new has little impact on resource use. 
For an outpatient clinic a new patient 
often utilizes more resources. 

• To the extent that there are follow-up 
visits for a patient, they typically occur at 
the same facility as the initial visit. 
These lower cost visits balance out the 
often more costly initial visit. 

• The designation of whether a patient is a 
new or old patient is not present on the 
Medicare UB-92 claim form. Thus, a 
change in reporting requirements would 
have been necessary. 

Patient complexity basically refers to the 
amount of time and tests normally 
required to treat a patient. In a visit based 



payment system, visit time is an important 
determinant of facility fixed cost because it 
directly affects both the number of visits 
that can be provided and the amount of 
overhead costs that are allocated to each 
visit. In forming the medical APGs, visit 
time was considered an important factor in 
the determination of resource use and the 
associated facility cost. Thus, separate 
medical APGs were formed to recognize 
differences in visit time. For example, a 
visit for a skin malignancy normally takes 
considerably less time than a visit for a 
hematological malignancy. 

The final issue that was considered in 
the formation of the medical APGs was the 
amount and type of ancillary services that 
are typically provided to a patient. 
Because the cost of some ancillary ser- 
vices would be included in the base visit 
payment, patients with different profiles of 
ancillary service use needed to be in dif- 
ferent APGs. 

Development of Ancillary Service APGs 

Ancillary services refer to ancillary tests 
(i.e., laboratory, radiology and pathology) 
and ancillary procedures (e.g., immuniza- 
tion, anesthesia, insertion of an lUD, etc.). 
Ancillary APGs were formed for each type 
of ancillary service. 

Laboratory 

The laboratory department in which the 
laboratory test is typically performed was 
used as the primary variable in the forma- 
tion of the laboratory APGs. Thus, tests 
performed by the different laboratory 
departments (e.g., hematology, microbiol- 
ogy, toxicology, etc.) were assigned to dif- 
ferent APGs. The testing method (e.g., 
radioimmunoassay) was used to a limited 
extent when the method represented a 
substantially different type of test with rela- 
tively clear indication for usage. However, 
in general, different methods of performing 



54 



Final Report 



■i-;i 



Description of APGs 



the same test were placed in the same 
APG. A laboratory technician will typically 
employ different methods depending on 
the precision of result that is needed. How- 
ever, different methods are also employed 
depending on the training of the laboratory 
professional. For example, although there 
is a clear difference between a fluorimetric 
versus chromatographic method in the 
determination of the calcium level, there 
frequently are not precise indications on 
when to do one versus the other. As a 
consequence, the different methods for 
performing the same test were usually 
assigned to the same APG. The same 
type of laboratory test (e.g., chemistry) 
was sometimes differentiated by the 
source of specimen (e.g., blood versus 
urine) in order to account for the labor cost 
of collecting and transporting the speci- 
men. Finally, the same type of laboratory 
test was usually differentiated based on 
the complexity of the test. Tests that 
required more time, technicians with 
greater skill levels or expensive equipment 
were assigned to different APGs. For 
example, multichannel chemistry tests 
were assigned to a separate APG from 
other chemistry tests because of the cost 
of the equipment used to perform a multi- 
channel chemistry test. Laboratory tests 
that required no equipment and are typi- 
cally performed during a visit (e.g., blood 
or urine dipstick tests) were assigned to a 
single APG as a result of their very low 
level of complexity. During the develop- 
ment of the laboratory APGs, physicians 
who either headed or worked in hospital 
laboratory departments and technicians 
who perform the tests were consulted. In 
addition, the laboratory relative value units 
(RVUs) developed by the College of 
American Pathologists were utilized. 

Radiology 

The type of equipment (magnetic reso- 



nance imaging [MRI], computerized 
assisted tomagraphy [CAT], plain film, 
etc.) was the primary classification vari- 
able for the radiology APGs because the 
cost of the radiology equipment varies 
considerably across the different types of 
radiological procedures. Nuclear medi- 
cine was separated into diagnostic and 
therapeutic groups. Five of the radiological 
APGs were considered significant proce- 
dures. These radiological APGs were 
interventional and met the definition of a 
significant procedure. 

Pathology 

Pathology was divided into two APGs 
based on the complexity of the pathology 
test. Pathology tests requiring more time 
or greater skill levels were assigned to the 
complex pathology APG. In addition, pap 
smears were assigned to a separate APG. 

Anesthesia APG 

All of anesthesiology was assigned to a 
single APG. The APG payment system 
includes the cost of anesthesia in the pay- 
ment for a significant procedure. The CPT- 
4 codes do not differentiate between gen- 
eral and local anesthesia and it was there- 
fore not possible to create separate 
general and local anesthesia APGs. How- 
ever, the procedures in each significant 
procedure APG typically have the same 
type of anesthesia administered. Thus, the 
absence of a differentiation on the type of 
anesthesia did not present a problem. 

Ancillary Tests and Procedures 

Other ancillary tests include electrocar- 
diograms, other minor cardiac and vascu- 
lar tests and pulmonary function tests. 
Ancillary procedures are procedures that 
do not dominate the time and resources 
expended during a visit, but do increase 
the time and resources expended during a 
visit. Thus, ancillary procedures can be 
performed as part of a medical visit and do 



The Development of a Physician Prospective Payment System for Ambulatory Care 



55 



Appendix A 



increase the cost of the medical visit. 
Ancillary procedures include immuniza- 
tions, introduction of needles and cathe- 
ters, biofeedback, infusion therapy, tube 
changes, minor reproductive procedures 
and minor ophthalmological procedures. 
Immunizations were divided into three 
APGs based primarily on the cost of the 
vaccine (e.g., rabies vaccination is consid- 
ered a complex immunization). 

Chemotherapy 

There are two significant procedure 
APGs for chemotherapy that are based on 
the route of administration of the chemo- 
therapy (i.e., intravenous push versus con- 
tinuous infusion). These two significant 
procedure APGs reflect the difference in 
supplies and the labor cost of monitoring 
the administration of the chemotherapy 
drug. There is a second major cost com- 
ponent associated with chemotherapy and 
that is the cost of the chemotherapy drug. 
Chemotherapy drug costs can vary con- 
siderably and, therefore, five additional 
chemotherapy APGs were formed to 
reflect the costs of chemotherapy drugs. 
Thus, the payment for a chemotherapy 
visit is composed of two APGs, one for the 
route of administration and one for the 
chemotherapy drug. 

Summary of Development 

The process of formulating the APGs 
was highly iterative, involving statistical 
results from historical data combined with 
clinical judgment. A preliminary classifica- 
tion was developed based solely on clini- 
cal judgment. The preliminary 
classification was then evaluated using 
several databases including both Medi- 
care and non-Medicare patients and con- 
tact time between provider and patient as 
well as charge data. The databases used 
in the development of Version 1 .0 of the 
APGs were as follows: 



• 1 987 Part B Medicare annual data con- 
sisting of summary charges by CPT-4 
code. 

• 1987 Medicare outpatient sample con- 
sisting of a 5 percent outpatient sample 
containing 232,827 procedure claims. 

• 1988 Medicare outpatient data contain- 
ing all Medicare hospital outpatients with 
a date of service from the last two weeks 
of October 1988 totalling 1.6 million out- 
patient claims. 

• 1988 New York State data containing 
approximately 400,000 claims from New 
York hospitals and community health 
centers including contact time between 
provider and patient. 

• 1985 National Ambulatory Care Survey 
Data consisting of 72,000 visits drawn 
from 2,789 office-based physicians that 
included contact time between provider 
and patient. 

• U.S. Army Ambulatory Care data base 
consisting of 516,006 visits to army hos- 
pitals and clinics that included contact 
time between provider and patient. 

• Relative Value Scales including Relative 
Values for Physicians (Relative Value 
Studies, Inc., 1984) and the Resource 
Based Relative Value Scale (RBRVS) 
(Hsaioetal, 1988). 

The database used in the development 
of Version 2.0 of the APGs was the HCFA 
Common Working File (CWF). The CWF is 
a comprehensive file of all services ren- 
dered to Medicare beneficiaries. An 
extract from the CWF of all visits to hospi- 
tal outpatient departments during the first 
three months of 1992 was obtained. The 
1992 data from the CWF contained 
14,883,101 claims. All claims for the same 
patient, for the same provider, on the 
same day were collapsed together into a 
single claim. The collapsing of claims 
reduced the CWF database from 
14,883,101 claims to 14,513,354 claims. 



56 



Final Report 



^- 



Description of APGs 



The 14,513,354 claims were then evalu- 
ated for ambiguities in the identification of 
claims as a single visit and edited for the 
presence of errors. After eliminating 
claims with errors and claims with unrea- 
sonable charges or cost values, there 
were 11,412,738 claims in the CWF data- 
base. 

The preliminary APG patient classes 
formed, based on clinical judgement, were 
evaluated using reports that displayed 
aggregate frequency and charge statistics 
as well as available RVU scales. For each 
CPT-4 code within an APG, the report for 
significant procedure and ancillary service 
APGs displayed the count, mean charge 
and standard deviation of charges from 
each data base as well as the available 
RVU scales. Using this report, the GPT-4 
codes that comprise each APG were eval- 
uated across all data bases and RVU 
scales simultaneously. The evaluation 
looked for consistency of average charges 
across the CPT-4 codes within an APG 
across all the data bases as well as for 
consistency across the available RVU 
scales. For each ICD-9-CM diagnosis 
code, the report for the medical APGs dis- 
played the summary statistics for charges 
and visit time. The evaluation of the medi- 
cal APGs looked for consistency of aver- 
age charges and visit time across the ICD- 
9-CM codes within an APG across all the 
data bases. As the APGs were being 
formed, the definitions were circulated to 
clinical consultants for comments on clini- 
cal appropriateness. Nearly 100 profes- 
sionals throughout the country 
commented and consulted on the con- 
stmction of the APGs. This process of 
defining APGs and reviewing them both 
clinically and with the data was repeated 
numerous times. The overall objective of 
the process was to have clinically similar 
groups of patients with similar resource 
use but to achieve these objectives with as 



few APGs as possible. 

During the formation of DRGs, charge 
data was, in general, found to reflect the 
relative needs of patients. The number of 
bed-days and ancillary services consumed 
by inpatients depended on their needs. 
However, hospital ambulatory charges are 
also highly influenced by physician 
charges. A great deal of effort has been 
expended in the development of RVUs, 
such as the RBRVS developed for physi- 
cian payment. RVU systems have been 
widely used for many years. Ambulatory 
charges for a procedure do not necessar- 
ily reflect the actual needs or complexity of 
an individual patient but are often based 
on the established RVU for the procedure. 
As a consequence, statistical results from 
charge data often simply reflect the estab- 
lished RVU scales. Although charge data 
were used extensively in the APG devel- 
opment, it was necessary for the clinical 
team to make judgments on whether 
observed hospital charge differences 
across different procedures reflect real dif- 
ferences in the resources required to per- 
form the procedure or any bias in the 
established RVU scales. 

For example, there are different CPT-4 
codes for excisions of benign and malig- 
nant skin lesions. RVU and charge data 
implied that excisions of malignant skin 
lesions of the same site and size used sig- 
nificantly more resources than benign skin 
lesions. However, the histology of the 
lesion is often not known at the time of the 
procedure, but is established when a 
pathology report is returned. Further, the 
excision of a malignant and benign skin 
lesion of the same site and size is funda- 
mentally the same procedure except that a 
wider margin is excised for lesions that are 
suspected to be malignant. Thus, the sig- 
nificant procedure APGs do not differenti- 
ate between malignant and benign skin 



The Development of a Physician Prospective Payment System for Ambulatory Care 



67 



Appendix A 



excisions. In addition, procedure APGs 
avoid assigning procedures to different 
APGs based on subtle or easily gameable 
distinctions in the CPT-4 codes. For exann- 
ple, deep and superficial muscle biopsies 
are in the sanne APG because the distinc- 
tion between deep and superficial lacks a 
precise definition in the CPT-4 system. 

The development of the APGs required 
a balance between the number of APGs, 
clinical consistency and homogeneity in 
charges and visit time. Clinical consis- 
tency was required in order for any proce- 
dures or diagnoses to be grouped into an 
APG. However, in general, APGs were not 
formed solely on clinical grounds. Verifica- 
tion of consistent differences in charges or 
visit time was required in order to fomn an 
APG. In general, infrequent APGs were 
not formed unless there was strong clinical 
justification and a large charge difference. 
For example, pacemaker replacements 
are infrequent on an outpatient basis, but 
pacemaker replacements do represent a 
clinically distinct group of patients with a 
very high cost. Thus, a pacemaker 
replacement APG was formed. The end 
result of the process of forming the APGs 
is a clinically consistent group of patient 
classes that are homogeneous in terms of 
resource use. 

The development of Version 2.0 of the 
APGs involved a complete reevaluation of 
the Version 1 .0 APG definitions. The deci- 
sion to make any APG Version 2.0 modifi- 
cations was based on a combination of 
clinical judgement and the results from the 
review of the CWF data. Decisions on spe- 
cific Version 2.0 modifications were made 
in the following manner. 

• Project medical staff, in conjunction with 
HCFA staff, made an initial assessment 
of the clinical meaningfulness of any 
potential APG modification. Potential 
APG modifications that are clinically 



unreasonable often occur when review- 
ing statistical data on the average 
charges or cost of individual CPT-4 pro- 
cedure or ICD-9-CM diagnosis codes. 
An individual code with a relatively low 
frequency of occurrence can some- 
times appear to be in the wrong APG 
based on historical data. Statistical 
results that had no clinical rationale 
were not used as the basis of APG mod- 
ifications. In general, potential APG 
modifications that were clinically unrea- 
sonable were not given further consider- 
ation. However, if the procedure or 
diagnosis in question occurred with a 
high frequency, additional confirmation 
was obtained from experts in the spe- 
cialty area. 

If, in the judgement of the project medi- 
cal staff and HCFA staff, there was any 
possible clinical merit to a potential APG 
modification, then the modification was 
reviewed with either the intemal clinical 
consultants or outside experts in the 
specialty area of the modification. A 
wide cross section of outside experts 
were consulted during the development 
of Version 2.0 of the APGs. The purpose 
of the review was to provide additional 
clinical confirmation for APG modifica- 
tions. While this was not a formal con- 
sensus panel process, every attempt 
was made to have all APG modifications 
clinically confirmed by outside experts. 
Any supporting data for the APG modifi- 
cations was also reviewed. The support- 
ing data that was evaluated included the 
historical cost or charges, relative val- 
ues if available, the amount and type of 
packaged ancillaries, the overall fre- 
quency of occurrences and the fre- 
quency of treatment in the emergency 
room. The coding implications of any 
APG modification were also taken into 
consideration. 

All APG modifications were developed 



58 



Final Report 



Description of APGs 



in close collaboration with HCFA staff. 
Frequent meetings and briefings were 
held with members of the research, 
operations, coding and policy staffs at 
HCFA. Operational and policy implica- 
tions of any APG modifications were dis- 
cussed and evaluated with HCFA staff. 
The final decision on all APG modifica- 
tions represents a consensus between 
the project staff and HCFA staff. 

Version 2.0 of the APGs has 282 APGs 
plus 8 error APGs, whereas Version 1 .0 of 
the APGs had 298 APGs plus one error 
APG. Table 3 contains the number of 
APGs by the different APG types. While 
the total number of APGs is relatively simi- 
lar, the vast majority of APGs had some 
significant modifications. Appendix A con- 
tains a complete list of the Version 2.0 
APGs. 

Figure 3 provides an overview of the 
APG Version 2.0 assignment logic. 
Patients with any significant procedures or 
therapies are assigned to one or more sig- 
nificant procedure APGs. If there are no 
significant procedures present and there is 
a medical visit indicator, the patient is 
assigned to a medical APG. if there is nei- 



ther a significant procedure nor a medical 
visit indicator present, but there are ancil- 
lary tests or procedures present, then the 
patient is only assigned one or more ancil- 
lary APGs. If there is no significant proce- 
dure, medical visit indicator or ancillary 
services present, the claim is considered 
an error. 

The APGs describe the complete range 
of services provided in the outpatient set- 
ting. The APGs can form the basic building 
blocks for the development of a visit- 
based outpatient prospective system and 
can provide a flexible structure for config- 
uring a payment system to meet specific 
policy objectives. 

The APG Payment System 

In the APG payment system a patient is 
described by a list of APGs that corre- 
spond to each service provided to the 
patient. The assignment of multiple APGs 
to a patient is in contrast with the DRG 
system that always assigns an inpatient to 
a single DRG. If a patient has multiple pro- 
cedures then the DRGs use a procedure 
hierarchy to select the most appropriate 
DRG. The DRG payment includes the cost 



APG Type 


Version 1.0 


Version 2.0 


Significant procedure 


145 


126 


Radiological significant procedure 





5 


Mental health and substance abuse 





8 


significant procedure 






Medical 


80 


83 


Laboratory 


23 


20 


Ancillary radiology 


20 


11 


Pathology 


2 


3 


Anesthesia 


1 


1 


Ancillary tests and procedures 


15 


18 


Chemotherapy 


3 


5 


Incidental 


8 


2 


Admitted or died 


1 





Error 


1 


8 


Total 


299 


290 


Table 3: Number of APGs by APG type 



The Development of a Physician Prospective Payment System for Ambulatory Care 



59 



Appendix A 



Error 




Significant Procedure 

or Therapy Visit 

APG 



Ancillary Only APGs 



Medical Visit APGs 



Figure 3 Overview of APG assignment logic 



of all ancillary services provided to the 
patient. In the outpatient setting, the diver- 
sity of sites of service (i.e., same day sur- 
gery units, emergency rooms and 
outpatient clinics), the wide variation in the 
reasons patients require outpatient care 
(e.g., well care to critical trauma care) and 
the high percentage of cost associated 
with ancillary services (i.e., the cost of 
ancillary services can often exceed the 
cost of the base visit) necessitates a 
patient classification scheme that can 
closely reflect the services rendered to the 
patient. The APGs address the diversity 
within the outpatient setting by assigning 
patients to multiple APGs when needed. 
For example, if a patient had two proce- 
dures performed plus a chest x-ray and a 
blood test, then there would be four APGs 
assigned to the patient (i.e., one APG for 
each procedure plus the APGs for the 
chest x-ray and the blood test). In a PPS, 
each APG would have a standard pay- 
ment rate, and the payment for a patient 
could be computed by summing the pay- 



ment rates across all the APGs assigned 
to the patient. However, in order to provide 
incentives for efficiency and to minimize 
opportunities for upcoding of APGs, not all 
the APGs assigned to a patient are used 
in the computation of the payment. The 
APG system uses two techniques for 
grouping different services provided into a 
single payment unit: ancillary packaging 
and multiple significant procedure and 
ancillary discounting. 

Ancillary Packaging 

A patient with a significant procedure or 
a medical visit may have ancillary services 
performed as part of the visit. Ancillary 
packaging refers to the inclusion of certain 
ancillary services into the APG payment 
rate for a significant procedure or medical 
visit. For example, a chest x-ray is pack- 
aged into the payment for a pneumonia 
visit. The packaging of ancillaries does not 
imply that there would be no payment 
associated with the packaged ancillary. 
The cost of the packaged ancillaries would 



m 



60 



Final Report 



Description of APGs 



be included in the payment amount for tine 
significant procedure or medical APG. For 
example, if a packaged ancillary cost $20 
and is perfomned for 50 percent of the 
patients in a medical APG, then $10 (i.e., 
50 percent of $20) would be included in 
the payment rate for the medical APG. 

Under Medicare's DRG-based PPS for 
hospital inpatient care, all ancillary ser- 
vices provided to a patient are packaged 
into the payment for the DRG to which the 
patient is assigned. Because of the nature 
of outpatient care, it is not clear that all 
services provided or ordered during a visit 
can be packaged into one payment rate. 
Medicare's current payment system for 
ambulatory care involves separate pay- 
ments for ancillary services provided in 
conjunction with a visit. Ancillary packag- 
ing will allow the Medicare program to 
make a single payment for a well defined 
package of ambulatory services, thereby 
creating a consistent definition of services 
across providers. Packaging will give pro- 
viders the incentive to improve their effi- 
ciency by avoiding unnecessary ancillaries 
and by substituting less expensive but 
equally effective ancillary services for 
more costly options. 

There are also some potential problems 
in the packaging of ancillaries. Packaging 
places providers at financial risk. If expen- 
sive ancillaries that are not usually per- 
formed for a particular type of visit are 
included in the packaged payment then 
the financial risk may be excessive. For 
example, if a $500 test that occurs on 
average only once per hundred visits was 
packaged, then the packaged payment for 
each visit would include only $5 for this 
test. Therefore, only relatively inexpen- 
sive, frequently performed ancillaries are 
packaged. 

There are basically two alternative 
approaches to packaging: partial packag- 



ing or all inclusive packaging. Under par- 
tial packaging, ancillary services that are 
inexpensive or frequently provided, are 
packaged into the payment for the signifi- 
cant procedure or medical visit. However, 
other ancillary services, particularly those 
that are expensive or infrequently per- 
formed (such as MRIs), are paid as sepa- 
rate ancillary APGs. Partial packaging 
limits the providers' risk. Under an all 
inclusive packaging, all services (including 
expensive ancillaries) that are provided 
during a visit are packaged into the visit 
payment. The partial packaging option is 
the most appropriate option because it 
does not impose a high level of risk for 
providers. 

Because partial packaging was utilized 
in the APG payment system, the subset of 
ancillary services that would be packaged 
into a procedure or medical visit needed to 
be determined. There are two approaches 
to selecting the ancillaries to be packaged: 
clinical or uniform. 

A clinical packaging approach selects 
the ancillaries to be packaged on an APG 
specific basis. The ancillaries to be pack- 
aged are selected primarily on clinical 
grounds. Thus, only ancillaries that are 
clinically expected to be a routine part of 
the specific procedure or medical visit are 
packaged. The clinical approach has the 
benefit that the resulting package for a 
visit is clinically meaningful. 

The alternative to clinical packaging is to 
develop a uniform list of ancillaries that are 
always packaged into every significant 
procedure or medical visit. There are sev- 
eral advantages associated with a uniform 
packaging of ancillaries. A uniform pack- 
aging is administratively simple. Once the 
unifomn list of ancillaries is developed, 
both the Medicare fiscal intermediaries 
and providers will know that every ancil- 
lary on the list is always packaged. Thus, 



The Development of a Physician Prospective Payment System for Ambulatory Care 



61 



Appendix A 



the tracking of the ancillaries that are 
packaged is straightforward. Further, a 
uniform list of packaged ancillaries is sim- 
ple for hospitals to explain to their medical 
staff and thus, the incentive to efficiently 
utilize the packaged ancillaries can be 
effectively communicated. A uniform list of 
ancillaries is less prone to manipulation by 
providers. With a clinical packaging of 
ancillaries, procedure or medical visits 
have different levels of ancillaries pack- 
aged across the different APGs. Thus, 
there is an incentive to code the patient 
into the significant procedure or medical 
APG with the fewest packaged ancillaries. 
This presents a particular problem for 
medical visits in which multiple diagnoses 
are present. For medical visits with multi- 
ple diagnoses, the ancillary tests may be 
performed for the secondary diagnoses. 
Under a clinical packaging, low cost non- 
routine tests are not packaged into the 
visit payment. This provides a financial 
incentive for providers to perform such 
nonroutine tests. A uniform packaging 
includes a wider array of ancillaries in the 
packaging for each APG and thus, there is 
less opportunity for additional payments 
from nonroutine ancillaries. 

A uniform packaging of ancillaries was 
selected for use in the APG payment 
model. An attempt to develop a clinical 
packaging of ancillaries proved difficult. 
The administrative simplicity, the relative 
freedom from manipulation and the wider 
scope of uniform packaging of ancillaries 
led to its adoption. In general, the ancillar- 
ies in the unifonn packaging included 
ancillaries that are performed for a wide 
range of different types of visits and were 
relatively low cost compared with average 
cost of the procedure and medical APGs. 
Only relatively low cost ancillaries were 
included in the uniform packaging 
because if high cost ancillaries were pack- 
aged into the visit payment, the patients 



who required such ancillaries would cause 
a substantial financial loss for the hospital. 
The list of ancillaries included in the uni- 
form packaging is a policy decision. The 
cost of medical surgical supplies, drugs 
and all other facility related costs are 
included in the payment for a significant 
procedure or medical visit. The only 
exception is the cost of chemotherapy 
medication because it is frequently very 
costly. 

Discounting 

When multiple significant procedures 
are performed or when the same ancillary 
service is performed multiple times, a dis- 
counting of the APG payment rates can be 
applied. Discounting refers to a reduction 
in the standard payment rate for an APG. 
Discounting recognizes that the marginal 
cost of providing a second procedure to a 
patient during a single visit is less than the 
cost of providing the procedure by itself. 
For example, discounting could compen- 
sate for the reduced cost per procedure of 
doing multiple significant procedures at 
the same time. When multiple significant 
procedures are perfomried, in general, the 
patient preparation, use of the operating 
room and recovery time is shared between 
the two procedures. Thus, the cost of 
doing two procedures at the same time is 
less than the cost of doing the two proce- 
dures at two different times. Discounting 
can also be used to provide a financial 
incentive not to repeat the same ancillary 
service multiple times. Because the perfor- 
mance of multiple ancillaries in the same 
APG may be clinically necessary and 
appropriate, there is no consolidation of 
ancillaries within the same APG. Thus, 
each nonpackaged ancillary in the same 
APG will result in an additional payment. 
However, in order to provide some finan- 
cial incentive not to repeat ancillary tests, 
multiple ancillaries in the same APG could 



62 



Final Report 



'-rHW 



>-v; 



Description of APGs 



be discounted. The level of any discount- 
ing is a policy decision and would be 
detemnined during system implementation. 

The components of an APG payment 
system are shown in Figure 4. In this 
example, although there are four APGs 
assigned to the claim, only three of the 
APGs are used to compute the final pay- 
ment amount. The bunion procedure (APG 
32) and the hand and foot tenotomy (APG 
34) are significant procedures and would 
have separate APG payments. The pay- 
ment amount for the second significant 
procedure would be discounted. The sim- 
ple surgical pathology (APG 332) is pack- 
aged, but the CAT scan (APG 307) is not. 
A visit-based APG PPS with uniform ancil- 
lary packaging and multiple APG discount- 
ing would have many advantages over the 
current outpatient payment method such 
as the following: 

• Many similar units of service are aggre- 
gated together, greatly reducing the 
number of units of service. 

• The need to establish separate payment 
rates for minor differences in the unit of 
service is eliminated. 

• The opportunity for unbundling the units 
of service is greatly reduced. 

• There is a financial incentive to use 
packaged ancillary services efficiently. 

• Multiple procedures during a visit are 
reasonably compensated, but not 
excessively rewarded. 

• Payment of medical visits is based on 



the type of patient treated and not on the 
level of effort reported by the physician. 

The structure of the APG payment 
model provides considerable flexibility. By 
modifying the level of ancillary packaging 
and discounting, the incentives in the sys- 
tem can be altered in order to achieve 
specific policy objectives. 

APG Payment Simulation 

In order to evaluate the APG payment 
model, a payment simulation using the 
historical Medicare CWF data was per- 
formed. (Averill, Goldfield, et al 1997) The 
objective of the APG payment simulation 
was to evaluate the altemative formula- 
tions of the APG payment model. The 
design of an APG based outpatient PPS 
has five essential components: 

Basis of Payment Weights 

The APG payment weights can be com- 
puted based on either the charges or cost 
reported by hospitals. Since the markup 
from cost to charges can vary consider- 
ably across hospital outpatient depart- 
ments, there can be substantial 
differences in the payment weights com- 
puted from charges versus those com- 
puted from cost. 

Ancillary Packaging 

A patient with a significant procedure or 
a medical visit may have ancillary services 
performed as part of the visit. Ancillary 
packaging refers to the inclusion of certain 

















Ancillary 
Packaging 














APG 32 
APG 34 
APG 332 
APG 307 






Visit 
Payment 
Computation 

with 
Discounting 








-> 


APG 32 
APG 34 
APG 307 


—> 








APG 
Assignment 


-^ 




Visit 

























































Figure 4 APG Payment System 



The Development of a Physician Prospective Payment System for Ambulatory Care 



63 



Appendix A 



ancillary services into the APG payment 
rate for a significant procedure or medical 
visit. The extent of ancillary packaging is a 
policy decision and can vary from none to 
the full packaging of all low cost, routine 
ancillary tests and procedures. 

Outlier Policy 

Outliers are atypical cases that have 
costs much higher than the APG payment 
amount. Additional payments can be pro- 
vided to outlier cases. The extent of outlier 
payments can vary from none to a signifi- 
cant percentage of cases being provided 
outlier payments. 

Discounting 

When multiple significant procedures 
are performed or when the same ancillary 
service is performed multiple times, a dis- 
counting of the APG payment rates can be 
applied. 

Window of Time for Ancillary Packaging 

Packaged ancillary services delivered 
on the day of a significant procedure or 
medical visit will always be included in the 
APG payment. The window of time for 
including packaged ancillaries in the APG 
payment can be expanded beyond the day 
of the visit. 

The above components of an APG sys- 
tem can be configured to produce different 
formulations of an APG PPS. Thirteen dif- 
ferent formulations of an APG PPS were 
selected for evaluation. The thirteen for- 
mulations of the APG PPS are summa- 
rized in Table 4. 

Three alternative lists of packaged ancil- 
laries were examined in the APG impact 
simulations. The three alternative packag- 
ing lists are summarized in Table 5. The 
cost of medical surgical supplies and 
drugs, except for chemotherapy, are 
always packaged and included in the APG 
relative weights. The cost of all incidental 



services (i.e., APG 421) are also always 
packaged and included in the APG relative 
weights. The limited packaging option only 
packages the anesthesia services. The 
simple packaging option adds simple 
ancillary tests to the lists of packaged 
ancillaries. The full packaging option adds 
some additional ancillary services, plus 
some minor medical services, to the list of 
packaged ancillaries. 

Outlier payments essentially represent a 
stop loss provision that protects providers 
from extreme losses on any individual 
patient. Cost outlier values were estab- 
lished for each significant procedure and 
medical APG. If the cost of the patient 
exceeds the cost outlier value, then the 
total payment for the patient was com- 
puted as the standard APG payment 
amount plus 1 00 percent of the difference 
between the actual cost and the cost out- 
lier value. The cost outlier value was 
established based on a specified number 
of standard deviations above the mean for 
each APG. The precise number of stan- 
dard deviations above the mean was 
established such that a specified percent- 
age of total payments would be associated 
with outlier payments. Thus, the number of 
standard deviations varied depending on 
the exact percentage of total payments 
associated with outlier payments. Since 
there are some administrative costs asso- 
ciated with outlier payments, the cost out- 
lier value was constrained to be, at a 
minimum, $1700 for significant procedure 
APGs and $350 for medical APGs. Thus, 
for patients whose cost exceeds the cost 
outlier value, the total payment would be: 

Total payment = APG payment + 

(actual cost - outlier value) 

Outlier payments are only associated 
with significant procedure and medical 
claims; there are no outlier payments 
associated with ancillary only claims. 



64 



Final Report 



Description of APGs 


APG 


Basis of Relative 


Ancillary 




Ancillary 


Window of 


System 


Weights 


Packaging 


Outliers 


Discounting 


Time 


1 


Cost 


Limited 


1% 


No 


Same Day 


2 


Charge 


Limited 


1% 


No 


Same Day 


3 


Cost 


Full 


1% 


No 


Same Day 


4 


Charge 


Full 


1% 


No 


Same Day 


5 


Cost 


Simple 


1% 


No 


Same Day 


6 


Cost 


Limited 


None 


No 


Same Day 


7 " 


Cost 


Full 


None 


No 


Same Day 


8 


Cost 


Full 


3% 


No 


Same Day 


9 


Cost 


Limited 


3% 


No 


Same Day 


10 


Cost 


Limited 


1% 


Yes 


Same Day 


11 


Cost 


Full 


1% 


Yes 


Same Day 


12 


Cost 


Full 


1% 


No 


Three Days 


13 


Cost 


Full 


1% 


No 


Seven Days 



Table 4: Components of Altemative APG Systems 



Three outlier alternatives were evaluated: 
no outliers, one percent of total payments 
associated with outlier payments and 
three percent of total payments associated 
with outlier payments. The inpatient DRG 
system currently has 5.1 percent of total 
payments associated with outlier pay- 
ments. A 5.1 percent of total payments 
associated with outlier payments was not 
evaluated since it would produce a large 
volume of claims with outlier payments. 

If there are multiple significant proce- 
dures, the significant procedure with the 
highest relative weight is paid at 1 00 per- 
cent and each additional significant proce- 
dure is discounted by 50 percent. The 50 
percent multiple significant procedure dis- 
counting was included in all APG systems 
that were evaluated. In addition, a 20 per- 
cent discounting of multiple ancillaries in 
the same APG was evaluated. 

Packaged ancillary services delivered 
on the day of a significant procedure or 



medical visit are always included in the 
APG payment. The impact of expanding 
the window of time for including packaged 
ancillaries in the APG payment was evalu- 
ated. A three day and seven day window 
of time around the visit was evaluated 

Evaluation of the Thirteen Alternative 
Formulations of an APG PPS 

For each of the thirteen formulations of 
an APG PPS, the APG payment amount 
for each patient was computed and com- 
pared to historical patient cost (referred to 
as an APG simulation). The APG payment 
levels for each of the APG simulations 
were set such that the aggregate APG 
payment, including any outlier payments, 
was equal to the aggregate cost across all 
patients. Thus, each APG simulation was 
performed on a budget-neutral basis. The 
APG simulation adjusted each hospital's 
APG payments for variations in wage 
rates using the 1993 Medicare inpatient 
PPS wage rate adjustment factors. In 



The Development of a Physician Prospective Payment System for Ambulatory Care 



65 



Appendix A 



Full Simple Limited 



APG 



X 


X 


310 


X 


X 


X 321 


X 


X 


332 


X 


X 


343 


X 


X 


345 


X 


X 


347 


X 


X 


349 


X 


X 


350 


X . 


X 


351 


X 


X 


356 


X 


X 


358 


X 


X 


359 


X 


X 


360 


X 




371 


X 


X 


373 


X 


X 


383 


X 




384 


X 




385 


X 




386 


X 




411 



Plain Film 

Anesthesia 

Simple Pathology 

Simple Immunology Tests 

Simple Microbiological Tests 

Simple Endocrinology Tests 

Simple Chemistry Tests 

Basic Chemistry Tests 

Multichannel Chemistry Tests 

Simple Clotting Tests 

Simple Hematology Tests 

Urinalysis 

Blood and Urine Dipstick Tests 

Simple Pulmonary Function Tests 

Cardiogram 

Intro of Needle and Catheter 

Dressings and Other Minor Proc 

Other Misc Ancillary Proc 

Biofeedback and Other Training 

Psychotropic Med Management 



Table 5 Alternative APG Packaging Options 



applying the wage rate adjustment factors, 
it was assumed that each hospital had 
71.4 percent of its cost associated with 
labor. This is the same percentage used in 
the inpatient PPS. 

Medicare payment for hospital outpa- 
tient services is based on a complex and 
confusing collection of payment methods. 
The current Medicare system pays hospi- 
tal outpatient services under a number of 
different methods including fee schedules, 
blended payment methods and cost based 
payments. It was beyond the scope of this 
project to compute actual historical Medi- 
care outpatient payments and compare 
actual payments to APG based payments. 
Thus, the results of the thirteen APG simu- 
lations do not reflect the actual payment 
impact on hospitals because the actual 
payments to hospitals based on the cur- 
rent complex and confusing system were 



not calculated. In addition, APG payment 
rates were not calculated based on the 
current level of Medicare program expen- 
ditures, which is less than hospital costs, 
but instead, were calculated based on 
what total program expenditures would be 
under a pure cost based system. Thus, for 
purpose of comparing the thirteen different 
APG simulations, hospital payments under 
each formulation of an APG PPS were 
computed with the constraint that in the 
aggregate. Medicare total expenditures 
under any of the APG simulations was 
equal to total hospital costs. The most 
basic of the thirteen formulations of an 
APG PPS was selected as the reference 
APG simulation and the relative APG pay- 
ment impact was computed by comparing 
cost based APG payments under each of 
the other APG simulations to the reference 
APG simulation. The relative APG pay- 



Final Report 



i-7 



Description of APGs 



ment impact was computed for different 
categories of hospitals and was used to 
evaluate eacfi component of the APG sys- 
tem (e.g., the extent of outlier payments) 
in terms of its relative payment impact 
across the different categories of hospi- 
tals. 

Converting Charges to Cost 

Based on the provider number, each 
claim was linked to a file provided by 
HCFA that contained departmental cost- 
to-charge ratios for each hospital. The 
charges on a claim were converted to cost 
by using the departmental cost-to-charge 
ratios. If there were no cost-to-charge 
ratios available for a hospital, the claims 
from that hospital were eliminated from the 
analysis. If a cost-to-charge ratio for the 
hospital was missing for only a subset of 
departments in a hospital, then the overall 
hospital cost-to-charge ratio was used for 
those departments. In general, the cost-to- 
charge ratios for ancillary departments 
tended to be lower than for other hospital 
departments. For example, the average 
cost-to-charge ratio for diagnostic radiol- 
ogy, laboratory and electrocardiology were 
0.66, 0.54 and 0.39, respectively. In com- 
parison, the average cost-to-charge ratio 
for clinics, emergency room and operating 
room were 1.30, 1.06 and 0.77, respec- 
tively. 

Computing APG Relative Weiglits 

Relative weights for each APG were 
computed. Relative weights can be com- 
puted based on either historical charges or 
cost. APG simulations were performed 
using relative weights computed from both 
charges and cost in order to determine if 
the basis of the relative weights resulted in 
a substantial impact in relative APG pay- 
ment. The APG relative weights for signifi- 
cant procedure or medical APGs include 
the costs associated with any ancillaries 



that are packaged into these APGs. 

Using charges and the three different 
packaging options, three sets of charge- 
based APG relative weights were com- 
puted. In addition, using costs and the 
three different packaging options, three 
sets of cost based APG relative weights 
were computed. The relative weights were 
computed based on the average cost or 
charge in each APG. The relative weights 
for significant procedure APGs were com- 
puted using only claims that had a single 
significant procedure because it was not 
possible to allocate accurately the costs 
(e.g., pharmaceuticals, medical-surgical 
supplies, etc.) across multiple significant 
procedure APGs. 

In order to obtain an accurate estimate 
of the average cost or charge, it was nec- 
essary to eliminate the extreme charge or 
cost values from the computation of the 
average. In the computation of the inpa- 
tient DRG relative weights, claims with 
charges that were more than three stan- 
dard deviations above the mean of the log 
of charges were eliminated. The same 
method of eliminating extreme charge or 
cost values was used in computing the six 
sets of APG relative weights. The percent 
of claims trimmed from the computation of 
the relative weights was only a fraction of 
one percent. 

The relative weights computed from 
charges and cost were essentially the 
same. The Pearson correlation coefficient 
between charge based and cost based rel- 
ative weights, with limited, simple and full 
packaging, was 0.990, 0.991 and 0.992, 
respectively. However, due to the lower 
cost-to-charge ratio for ancillary depart- 
ments, the relative weights for ancillary 
APGs tend to be proportionately lower for 
cost based weights than for charge based 
weights. 



The Development of a Physician Prospective Payment System for Ambulatory Care 



67 



Appendix A 








Charge Based 
Relative Weights 


Cost Based 
Relative Weights 




Count 


Full Simple 
Package Package 


Limited 
Package 


Full Simple Limited 
Package Package Package 


Significant Procedure Claims 

Medical Claims 

Significant Procedure and 
Medical Claims Combined 


1,567.263 
2,186,728 
3.753.991 


11.90 11.64 
45.38 45.20 
20.00 19.76 


3.62 
0.94 
3.20 


9.24 9.00 2.51 
31.34 31.18 0.52 
15.44 15.22 2.07 



Table 6: Percent of APG Relative Weights Derived from Packaged Ancillaries 



Table 6 contains the overall percent of 
the relative weights derived from pack- 
aged ancillaries for the six sets of relative 
weights. In general, the percent of the rel- 
ative weight from packaged ancillaries 
tends to be lower for cost based relative 
weights than for charge based relative 
weights. This reflects the relatively low 
cost-to-charge ratios associated with the 
ancillary departments. The medical APGs 
have a much higher percentage of the 
APG relative weight from packaged ancil- 
laries than the significant procedure 
APGs. For the cost based relative weights 
with full packaging, the relative weight with 
the highest percent of the APG relative 
weight from packaged ancillaries is the 
medical APG for chest pain with cardiac 
enzymes to rule out myocardial infarction 
(APG 573), at 46.2 percent. The high per- 
cent of packaged ancillaries associated 
with this APG is the result of the packag- 
ing of the extensive laboratory tests that 
are performed for this type of patient. In 
general, the percent of the relative weight 
from packaged ancillaries tends to be 3 to 
4 times higher for medical APGs than for 
significant procedure APGs. The high per- 
cent of the relative weights from packaged 
ancillaries for medical patients is primarily 
the result of the relatively low payment for 
a medical claim. The APG with the lowest 
percent of the APG relative weight from 
packaged ancillaries is the significant pro- 
cedure APG for laser eye procedures 



(APG 213), at 0.22 percent. 

Comparison of Alternative APG 
Systems 

The thirteen APG simulations were com- 
pared by computing an overall R^ which 
provides a measure of the amount of vari- 
ance in historical cost explained by the 
APG payment system. Positive values that 
approach 1 .0 for R2 would indicate that the 
relative value of the total APG payment 
closely approximates the relative value of 
the historical cost. Table 7 contains the R2 
for all thirteen APG simulations. Based on 
the results in these tables, the impact of 
each of the alternative formulations of an 
APG PPS was evaluated. 

Cost Based and Charge Based Relative 
Weights 

From Table 7, APG Systems 1 and 2 
compare the effects of using relative 
weights based on charges and cost with 
the limited packaging option, while APG 
Systems 3 and 4 make the same compari- 
son with the full packaging option. All four 
APG systems have one percent of pay- 
ments associated with outliers, no ancil- 
lary and a same day window. The R^ for 
APG System 1 compared to APG System 
2 is virtually identical, and the R2 for APG 
System 3 compared to APG System 4 is 
also virtually identical. Thus, the cost of 
individual R2 for alternative APG Systems 
patients can be predicted equally well (i.e.. 



68 



Final Report 



Description of APGs 


_ 


APG 

Systems 


Sig 
Free 


Medical 


Medical 

Plus Sig 

Proc 


Anc 
Only 


Total 


Basis 
Wghts 


Anc 
Pkg 


Out 


Anc 
Disc 


Window 

of 

Time 


1 


0.683 


0.745 


0.686 


0.746 


0.773 


Cost 


Lim 


1% 


No 


Same Day 


2 


0.688 


0.744 


0.690 


0.739 


0.774 


Chg 


Lim 


1% 


No 


Same Day 


3 


0.668 


0.588 


0.660 


0.746 


0.757 


Cost 


Full 


1% 


No 


Same Day 


4 


0.669 


0.589 


0.661 


0.739 


0.756 


Chg 


Full 


1% 


No 


Same Day 


5 


0.668 


0.590 


0.660 


0.746 


0.757 


Cost 


Sim 


1% 


No 


Same Day 


6 


0.620 


0.439 


0.605 


0.746 


0.721 


Cost 


Lim 


None 


No 


Same Day 


7 


0.601 


0.264 


0.575 


0.746 


0.701 


Cost 


Full 


None 


No 


Same Day 


8 


0.734 


0.726 


0.733 


0.746 


0.804 


Cost 


Full 


3% 


No 


Same Day 


9 


0.760 


0.804 


0.762 


0.746 


0.823 


Cost 


Lim 


3% 


No 


Same Day 


10 


0.682 


0.744 


0.684 


0.746 


0.772 


Cost 


Lim 


1% 


Yes 


Same Day 


11 


0.668 


0.587 


0.660 


0.746 


0.756 


Cost 


Full 


1% 


Yes 


Same Day 


12 


0.665 


0.592 


0.657 


0.747 


0.755 


Cost 


Full 


1% 


No 


3 Days 


13 


0.664 


0.596 


0.656 


0.747 


0.754 


Cost 


Full 


1% 


No 


7 Days 








Table 7: 


R- for alternative APG systems 











obtain the same R^) using relative weights 
computed from charges or relative weights 
computed from costs. 

Alternative Ancillary Packaging Lists 

APG Systems 1 , 3 and 5 use limited, full 
and simple packaging, respectively, with 
cost based relative weights, one percent 
of payments associated with outliers, no 
ancillary discounting and a same day win- 
dow of service. The simple packaging and 
the full packaging have virtually identical 
R2 results. The R^ for significant proce- 
dure claims is 2.2 percent lower with full 
packaging (0.668 versus 0.683). For medi- 
cal claims, the R^ is 21.1 percent lower 
with full packaging than it is with limited 
packaging (0.588 versus 0.745). The 
lower R2 for medical claims with the full 
packaging option reflects the combined 
effect of the variability in the use of ancil- 
laries for medical visits coupled with ancil- 
laries being a large percent of the cost of a 
medical visit. 

Outliers 

APG Systems 6, 1 and 9 use percent, 
1 percent and 3 percent of payments 
associated with outliers, respectively, with 



the limited packaging option, cost based 
relative weights, no ancillary discounting 
and a same day window of time. For sig- 
nificant procedure APGs, the 3 percent 
outlier option has the highest R^, while the 
1 percent outlier option is 10.1 percent 
lower (0.760 versus 0.683) and the no out- 
lier option is 18.4 percent lower (0.760 ver- 
sus 0.620). For medical APGs, the 3 
percent outlier option has the highest R^, 
while the 1 percent outlier option is 7.3 
percent lower (0.804 versus 0.745) and 
the no outlier option is 45.4 percent lower 
(0.804 versus 0.439). Thus, there is a 
small reduction in R2 if outlier payments 
are reduced from 3 percent to 1 percent, 
but a large reduction in R^ for medical 
claims if outlier payments are eliminated 
entirely. 

APG Systems 7, 3 and 8 use percent, 
1 percent and 3 percent payments associ- 
ated with outliers with the full packaging 
option, cost based relative weights, no 
ancillary discounting and a same day win- 
dow of service. For significant procedure 
APGs, the 3 percent outlier option has the 
highest R^, while the 1 percent outlier 
option is 9.0 percent lower (0.734 versus 



The Development of a Physician Prospective Payment System for Ambulatory Care 



Appendix A 



0.668) and the no outlier option 18.1 per- 
cent lower (0.734 versus 0.601). For medi- 
cal APGs, the 3 percent outlier option has 
the highest R2, while the 1 percent outlier 
option is 1 9.0 percent lower (0.726 versus 
0.588) and the no outlier option is 63.6 
percent lower (0.726 versus 0.264). Thus, 
with full packaging, there is a modest 
reduction in R^ by reducing the outlier pay- 
ments from 3 percent to 1 percent and a 
large reduction in R2 for medical claims if 
outlier payments are eliminated entirely. 

While the 3 percent outlier option has 
the highest R^ it also results in significantly 
more claims having outlier payments. APG 
Systems 1 and 3, which use the 1 percent 
outlier option, have 1.277 percent and 
1.241 percent of claims with outlier pay- 
ments, respectively. APG Systems 8 and 
9, which use the 3 percent outlier option, 
have considerably more claims with outlier 
payments with 4.571 percent and 3.588 
percent of claims with outlier payments, 
respectively. 

Ancillary Discounting 

APG System 1 adds ancillary discount- 
ing to APG System 1 . APG Systems 1 and 

10 have limited packaging, with cost 
based relative weights, one percent of 
payments associated with outliers and a 
same day window of service. APG System 

11 adds ancillary discounting to APG Sys- 
tem 3. APG Systems 3 and 11 have full 
packaging, with cost based relative 
weights, one percent of payments associ- 
ated with outliers and a same day window 
of sen/ice. The R^ for APG Systems 1 and 
10 and the R2 for APG Systems 3 and 11 
are virtually identical. Thus, there is virtu- 
ally no reduction in R2 from ancillary dis- 
counting. 

Window of Time 
In order to simulate a window of time of 



three days and seven days for APG Sys- 
tems 1 2 and 1 3, respectively, it was nec- 
essary to collapse some of the ancillary 
only claims into a significant procedure or 
medical claim. Thus, if there was an ancil- 
lary only claim for a patient two days fol- 
lowing a medical visit, the ancillary only 
claim was deleted and the ancillary ser- 
vices provided were incorporated into the 
medical visit claim. In addition, the 
expanded window of time created some 
ambiguous situations, which necessitated 
the exclusion of some additional claims. 
For example, if the same ancillary only 
claim occurred two days after a medical 
visit and two days prior to a significant pro- 
cedure visit, then it would be ambiguous 
as to whether the ancillary only claim 
should be associated with the medical visit 
or the significant procedure visit. In this 
example, all three claims would be 
excluded from the analysis because of the 
ambiguity. There were only a small per- 
centage of significant procedure or medi- 
cal claims eliminated due to ambiguities, 
and 3.02 percent and 6.65 percent of the 
ancillary only claims were collapsed or 
eliminated due to ambiguities for the three 
day and seven day window of time, 
respectively. 

As a result of the expanded window of 
time, a larger proportion of the cost of a 
significant procedure or medical visit was 
associated with packaged ancillaries. For 
the full packaging option, the percentage 
of the APG cost associated with packaged 
ancillaries was 15.94, 15.83 and 16.32 
percent for the one day, three day and 
seven day window of time, respectively. 
Thus, there was only a very small increase 
in the percentage of APG cost from pack- 
aged ancillaries as the window of time was 
expanded. 

APG Systems 3, 12 and 13 use a same 
day, three day and seven day window of 



70 



Final Report 



Description of APGs 



• 



time, respectively, with cost based 
weiglnts, full ancillary packaging, 1 percent 
outliers, 50 percent multiple significant 
procedure discounting and no ancillary 
discounting. The R^ for all three APG sys- 
tems is virtually the same. Thus, there is 
no substantial impact on R^ as a result of 
expanding the window of time of ancillary 
packaging. 

Comparison of Version 2.0 APGs and 
DRGs 

Medicare inpatient data was used to 
compute the R^ for the DRGs. In the pay- 
ment model used for the DRG analysis, 
the payment for each patient was com- 
puted as the average standardized charge 
for the DRG to which the patient was 
assigned. 

The APG simulation that most closely 
approximates the untrimmed DRGs is 
APG System 7, which uses cost based 
weights with full packaging, no outliers, 
significant procedure discounting, no 
repeat ancillary discounting and a same 
day window of time. Table 8 compares the 
R2 for APGs and DRGs. 





Untrimmed 


APG 




DRGs 


System 7 


Procedure discharges/visits 


0.425 


0.601 


Medical discharges/visits 


0.267 


0.264 


Combined procedure/medi- 


0.394 


0.575 


cal discharges visits 







Table 8: R- for DRGs and APGs 

The R2 for untrimmed (i.e., without outli- 
ers for APGs) procedure and medical 
claims combined is higher for APGs than 
for DRGs (i.e., 0.575 for APGs versus 
0.394 for DRGs). For procedure claims, 
the APGs have a higher R2 than the DRGs 
(i.e., 0.601 for APGs versus 0.425 for 
DRGs). For medical claims the DRGs 



have a slightly higher R^ than the APGs 
for untrimmed claims (i.e., 0.264 for APGs 
versus 0.267 for DRGs). The higher R2 for 
the APGs means that the APGs predict 
historical outpatient costs better than the 
DRGs predict historical standardized inpa- 
tient charges. 

Hospital APG Impact Simulation 

Hospital characteristics were identified 
by linking the provider number on each 
claim to the FY1993 PPS Payment Impact 
File. Hospitals were categorized into 67 
categories. The categories were not mutu- 
ally exclusive and the same hospital could 
appear in multiple categories. The hospital 
categories replicated the hospital catego- 
ries used by HCFA to display the inpatient 
PPS impact results. All information neces- 
sary to create the hospital categories was 
available in the FY 1993 PPS Payment 
Impact File, except hospital ownership. 
Hospital ownership was obtained using a 
separate file provided by HCFA. 

The hospital categorization was done in 
two different ways, one based on geo- 
graphic location and the other on payment 
categories. In the geographic location sec- 
tion, the metropolitan statistical area 
(MSA), the region of the country and the 
urban/rural status is based on the actual 
location of the hospital. Since these hospi- 
tal location characteristics affect the inpa- 
tient PPS payment levels, the Executive 
Office of Management and Budget reclas- 
sifies the urban/rural designation, as well 
as the MSA and geographic region. In the 
payment categories section the MSA, the 
region of the country and the urban/rural 
status was based on the reclassified loca- 
tion of the hospital used in the inpatient 
PPS. 

The FY 1993 PPS Payment Impact File 
contained 5,491 hospitals. Only hospitals 
covered by the inpatient PPS were 



The Development of a Physician Prospective Payment System for Ambulatory Care 



71 



Appendix A 



included in the PPS Payment Impact File. 
The analysis database included 5,118 
(92.3 percent) of the PPS hospitals. In 
addition, the analysis database contained 
data from 356 hospitals that were not cov- 
ered by the inpatient PPS (e.g., psychiatric 
hospitals). The non PPS hospitals had 
very few claims per hospital in the analysis 
database. For PPS hospitals there was an 
average of 2,222 claims per hospital in the 
analysis database, but for non PPS hospi- 
tals there was only an average of 60.2 
claims per hospital. There were also 16 
hospitals that were PPS hospitals that 
were not in the 1993 PPS Payment Impact 
File. Since the data was from 1992, these 
are probably hospitals that closed or 
merged with other hospitals in 1993. In 
total, there were 5,490 hospitals in the 
analysis database. 

Table 9 and Table 10 contain for each 
hospital category the impact of each of the 
13 APG systems. APG System 6 repre- 
sents the most basic version of an APG 
system. APG System 6 uses cost based 
relative weights, limited packaging, no out- 
liers, no ancillary discounting and a same 
day window of time. The impact of an APG 
system APG system was measured by 
taking the aggregate APG payment to 
hospitals in the hospital category under 
the APG system, subtracting the aggre- 
gate APG payments to hospitals in the 
hospital category under APG System 6 
and dividing the difference by the aggre- 
gate APG payments to hospitals in the 
hospital category under APG System 6. 
The result is the percent difference 
between hospital payments under the 
APG system being evaluated and hospital 
payments under APG System 6. A impact 
of +2.0 would indicate that the hospitals in 
the hospital category would receive two 
percent more in aggregate payments 
under the APG system being evaluated 
than the hospitals would have under the 



basic APG system (i.e., APG System 6). 
The relative APG payment impact mea- 
sures how the aggregate payments to 
hospitals in each hospital category would 
change as the basic APG system (i.e., 
APG System 6) is expanded (e.g., more 
extensive ancillary packaging, the addition 
of outlier payments, etc.). Thus, the rela- 
tive APG payment impact provides a 
means of evaluating each component of 
the APG system in terms of its effect on 
aggregate APG based payments to differ- 
ent categories of hospitals. It does no^ pro- 
vide a measure of the change in actual 
payments that hospitals would receive 
under an APG payment system. The dis- 
cussion of the relative APG payment 
impact is based on Table 6 and Table 7. 
APG System 1 adds one percent outlier 
payments to the basic APG system (i.e., 
APG System 6) and APG System 9 adds 
three percent outlier payments. There was 
relatively little APG payment impact 
across categories of hospitals as a result 
of adding outlier payments to the APG 
system. In general, the APG payment 
impact with outlier payments added was 
within one percent of the basic APG sys- 
tem. 

The discussion of the relative APG pay- 
ment impact is based on Table 9 and Table 
10. APG System 1 adds 1% outlier pay- 
ments to the basic APG system (i.e., APG 
System 6), and APG System 9 adds 3% 
outlier payments. There was relatively little 
APG payment impact across categories of 
hospitals as a result of adding outlier pay- 
ments to the APG system. In general, the 
APG payment impact with outlier pay- 
ments added was within 1% of the basic 
APG system. 

APG System 7 adds full packaging to 
the basic APG system. The addition of full 
packaging does tend to have a substantial 
APG payment impact across categories 



12 



Final Report 



3. 



I 

S 

3 
•V 

S 



A 



C9 



9 

> 
3 



s 















APG Syst 


em 












Hospital Categories 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


LOCATION: 




























URBAN HOSPITALS 


0.00 


-0.25 


-0.07 


-0.34 


-0.05 


0.00 


-0.08 


0.01 


0.12 


-0.01 


-0.07 


-0.16 


-0.68 


LARGE URBAN AREAS 


0.13 


-0.68 


0.19 


-0.62 


0.23 


0.00 


0.04 


0.55 


0.56 


0.11 


0.18 


0.11 


-0.42 


OTHER URBAN AREAS 


-0.13 


0.23 


-0.35 


-0.03 


-0.36 


0.00 


-0.21 


-0.59 


-0.38 


-0.13 


-0.36 


-0.47 


-0.97 


RURAL AREAS 
BED SIZE (URBAN): 


-0.07 


1.11 


0.17 


1.42 


0.10 


0.00 


0.26 


-0.17 


-0.51 


-o:o3 


0.20 


-0.20 


-0.82 














0-99 BEDS 


0.55 


0.87 


0.43 


0.71 


0.41 


0.00 


-0.13 


1.27 


1.38 


0.60 


0.47 


0.12 


-0.41 


100-199 BEDS 


0.05 


0.36 


-0.31 


-0.07 


-0.29 


0.00 


-0.39 


0.27 


0.74 


0.03 


-0.31 


-0.44 


-1.03 


200-299 BEDS 


0.06 


0.76 


-0.58 


-0.02 


-0.55 


0.00 


-0.65 


-0.52 


0.15 


0.05 


-0.59 


-0.68 


-1.11 


300-499 BEDS 


-0.17 


-0.36 


-0.34 


-0.57 


-0.33 


0.00 


-0.18 


-0.63 


-0.47 


-0.18 


-0.35 


-0.34 


-0.79 


500 OR MORE BEDS 
BED SIZE (RURAL): * 
0-49 BEDS 


-0.06 


-3.02 


1.42 


-1.23 


1.43 


0.00 


1.51 


1.25 


-0.18 


-0.07 


1.40 


1.28 


0.56 


0.50 


0.87 


2.77 












0.14 


0.51 


2.81 


2.31 


1.75 


3.65 


2.59 


0.00 


2.38 


2.85 


50-99 BEDS 


0.03 


1.29 


0.34 


1.72 


0.25 


0.00 


0.34 


0.21 


-0.27 


0.05 


0.38 


-0.17 


-0.91 


100-149 BEDS 


-0.25 


1.43 


-0.66 


0.95 


-0.72 


0.00 


-0.38 


-1.12 


-0.78 


-0.20 


-0.64 


-1.00 


-1.65 


150-199 BEDS 


-0.30 


0.88 


-0.50 


0.65 


-0.53 


0.00 


-0.19 


-1.30 


-1.09 


-0.25 


-0.48 


-0.65 


-1.18 


200 OR MORE BEDS 


-0.33 


0.86 


-0.97 


0.10 


-0.96 


0.00 


-0.64 


-1.48 


-0.73 


-0.28 


-0.95 


-1.24 


-1.71 


URBAN BY CENSUS DIV: 




























NEW ENGLAND 


-0.59 


-2.36 


0.25 


-1.44 


0.29 


0.00 


0.83 


-0.24 


-0.87 


-0.59 


0.25 


-0.30 


-1.50 


MIDDLE ATLANTIC 


-0.23 


-0.01 


0.36 


0.66 


0.37 


0.00 


0.60 


0.63 


0.36 


-0.18 


0.37 


-0.12 


- 1 .83 


SOUTH ATLANTIC 


0.18 


0.21 


-0.76 


-0.90 


-0.75 


0.00 


-0.98 


-0.47 


0.38 


0.15 


-0.77 


-0.72 


-0.83 


EAST NORTH CENTRAL 


-0.28 


0.16 


-0.57 


-0.22 


-0.56 


0.00 


-0.30 


-0.81 


-0.40 


-0.31 


-0.57 


-0.78 


-1.50 


EAST SOUTH CENTRAL 


0.24 


0.38 


-0.57 


-0.55 


-0.59 


0.00 


-0.83 


-0.67 


0.08 


0.22 


-0.60 


-0.63 


-0.81 


WEST NORTH CENTRAL 


0.22 


-0.18 


0.10 


-0.30 


0.17 


0.00 


-0.12 


-0.08 


-0.04 


0.18 


0.08 


0.13 


0.04 


WEST SOUTH CENTRAL 


0.68 


0.36 


-0.41 


-0.88 


-0.48 


0.00 


-1.16 


0.57 


1.64 


0.58 


-0.43 


-0.12 


0.12 


MOUNTAIN 


0.38 


-2.35 


1.81 


-0.58 


1.73 


0.00 


1.46 


2.13 


0.39 


0.37 


1.79 


1.91 


1.66 


PACIFIC 


O.IO 


-0.43 


0.51 


0.03 


0.60 


0.00 


0.46 


0.49 


-0.06 


0.15 


0.50 


0.71 


0.89 


PUERTO RICO 

RURAL BY CEmMmP: 


-0.93 


-4.28 


2.07 


-0.14 


2.16 


0.00 


3.03 


0.34 


-2.51 


-0.87 


2.14 


2.46 


1.83 
















NEW ENGLAND 


-0.51 


1.57 


0.02 


2.11 


0.02 


0.00 


0.56 


-0.44 


-0.91 


-0.37 


0.08 


-0.41 


-1.15 


MIDDLE ATLANTIC 


-0.70 


1.03 


0.16 


1.98 


0.09 


0.00 


0.89 


-1.32 


-2.11 


-0.63 


0.15 


-0.87 


-2.86 


SOUTH ATLANTIC 


0.15 


1.06 


-1.00 


-0.23 


-0.97 


0.00 


-1.18 


-0.91 


-0.03 


0.14 


-0.97 


-1.19 


-1.51 


EAST NORTH CENTRAL 


-0.21 


2.26 


-0.82 


1.53 


-0.88 


0.00 


-0.59 


-1.30 


-0.69 


-0.21 


-0.79 


-1.37 


-2.33 


EAST SOUTH CENTRAL 


-0.27 


0.80 


0.00 


1.23 


-0.08 


0.00 


0.31 


-0.76 


-1.10 


-0.25 


0.02 


-0.36 


-0.76 


WEST NORTH CENTRAL 


0.18 


0.67 


1.43 


2.19 


1.36 


0.00 


1.34 


1.23 


-0.15 


0.27 


1.46 


1.02 


0.45 


WEST SOUTH CENTRAL 


0.26 


0.17 


0.97 


1.12 


0.76 


0.00 


0.72 


1.30 


0.49 


0.24 


0.99 


0.76 


0.52 


MOUNTAIN 


0.07 


1.12 


1.82 


3.22 


1.66 


0.00 


1.84 


1.48 


-0.44 


0.15 


1.86 


1.65 


1.61 


PACIFIC 


-0.16 


0.76 


1.10 


2.25 


1.00 


0.00 


1.31 


0.63 


-0.85 


-0.07 


1.14 


1.13 


0.90 


PUERTO RICO 


-0.96 


1.41 


2.35 


5.64 


2.52 


0.00 


3.39 


0.51 


-2.86 


-0.73 


2.44 


0.16 


-5.43 



OJ 



Table 9: Impact by hospital categories by geographic location across APG systems 



a 





APG Systems 


Hospital Category 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


n 


12 


13 


PAYMENT LOCATION: 

URBAN HOSPITALS 
LARGE URBAN AREAS 
OTHER URBAN AREAS 
RURAL AREAS 


0.00 

0.07 

-0.09 

-0.06 


-0.18 

-0.55 

0.29 

1. 00 


-0.10 
0.08 

-0.33 
0.36 


-0.31 

-0.55 

0.00 

1.53 


-0.09 
0.12 

-0.35 
0.28 


0.00 
0.00 
0.00 
0.00 






0.10 

0.42 

-0.32 

-0.52 


-0.01 

0.05 

-0.09 

-0.01 


-O.I I 
0.08 

-0.34 
0.39 


-0.21 
-0.01 
-0.47 
-0.01 


-0.74 
-0.55 
-0.98 
-0.57 


-0.11 

-0.01 

-0.23 

0.45 


-0.03 
0.38 

-0.55 
0.00 


TEACHING STATUS: 




















NON-TEACHING 

RESIDENT TO BED RATIO < 25 

RESIDENT TO BED RATIO >= 25 

DISPROP SHARE HOSPITALS: 

NON-DSH 
URBAN DSH: 

100 BEDS OR MORE 
FEWER THAN 100 BEDS 

RURAL DSH: 


0.05 
-0.12 
-0.05 

-0.05 

0.06 
0.25 


1.28 

0.06 

-6.95 


-0.55 

-0.18 

3.33 


0.56 
-0.04 
-2.84 


-0.55 

-0.18 

3.37 


0.00 
0.00 
0.00 


-0.61 

-0.05 

3.42 


-0.48 

-0.30 

3.27 


0.04 

-0.14 

0.05 


0.05 
-0.11 
-0.08 


-0.54 

-0.17 

3.31 


-0.72 

-0.24 

3.02 

-0.55 


-1.14 

-0.80 

1.91 

-1.08 

-0.08 
-0.05 








-0.32 


-0.34 


-0.01 


-0.03 


-0.35 


0.97 

-1.59 
0.29 


-0.36 

0.56 
0.08 


0.58 


-0.36 


0.00 


-0.96 
0.17 


0.57 
0.08 


0.00 
0.00 


0.51 
-0.16 


0.56 
-0.15 






0.55 
0.12 


0.48 
0.07 


0.03 
-0.53 


0.03 
0.24 


SOLE COMMUNITY (SCH) 

RURAL REFERRAL CENTERS (RRC) 

OTHER RURAL DSH HOSP: 


0.08 
-0.23 


-0.08 
-0.96 


0.02 
-0.33 


0.01 
-1.00 


-0.12 
-0.25 


0.00 
0.00 


-0.04 
-0.08 


0.29 
-0.65 


0.09 
-0.56 


0.02 
-0.19 


0.05 
-0.32 


-0.13 
-0.51 


-0.29 
-0.96 


100 BEDS OR MORE 
FEWER THAN 100 BEDS 

URBAN TEACHING AND DSH: 

BOTH TEACHING AND DSH 
TEACHING AND NO DSH 
NO TEACHING AND DSH 
NO TEACHING AND NO DSH 

RURAL HOSPITAL TYPES: 


-0.37 
-0.06 

0.09 

-0.28 

0.03 

0.10 


0.27 
0.10 

-3.26 

-0.14 

0.86 

1.54 


-0.68 
1.25 

1.62 
-0.23 
-0.97 
-0.85 


-0.05 
1.83 

-1.38 

-0.13 

-0.32 

0.38 


-0.77 
1.12 

1.62 
-0.22 
-0.95 
-0.83 


0.00 
0.00 

0.00 
0.00 
0.00 
0.00 


-0.30 
1.33 

1.57 

0.05 

-1.03 

-0.98 


-1.17 
0.73 


-0.75 
-0.95 


-0.30 
-0.08 

0.05 
-0.25 
-0.01 

0.10 


-0.64 
1.28 

1.61 
-0.22 
-0.99 
-0.85 


-1.06 
1.04 

1.49 
-0.35 
-0.98 
-0.98 


-1.45 
0.85 

0.71 
-0.98 
-1.22 
-1.41 


1.45 
-0.20 
-0.73 
-0.65 


-0.11 
0.04 
0.22 
0.23 




















NONSPECIAL STATUS HOSPITALS 
RURAL REFERRAL CENTER (RRC) 
SOLE COMMUNITY HOSPITAL (SCH) 
SCH AND RRC 

MEDICARE DEPENDENT SMALL 
RURAL HOSPITAL 


0.00 
-0.43 

0.12 
-0.01 

0.39 


1.09 
0.83 
1.29 
0.46 
0.94 


0.60 
-0.67 

0.77 
-0.10 

1.93 


1.86 
0.53 
2.12 
0.34 
2.84 


0.52 
-0.70 

0.66 
-0.11 

1.80 


0.00 
0.00 
0.00 
0.00 
0.00 


0.64 
-0.24 

0.71 
-0.08 

1.60 


0.31 
-1.39 

0.74 
-0.95 

2.05 


-0.43 
-1.06 
-0.16 
-0.95 
0.24 


0.03 
-0.36 
0.16 
0.06 
0.40 


0.63 
-0.65 

0.81 
-0.08 

1.96 


0.09 
-0.90 

0.47 
-0.13 

1.36 


-0.58 
-1.37 
-0.03 
-0.33 
0.53 


TYPE OF OWNERSHIP: 




























VOLUNTARY 

PROPRIETARY 

GOVERNMENT 


-0.16 
0.40 
0.43 


0.35 

0.82 

-2.23 


-0.27 

-0.75 

1.84 


0.18 
-0.49 
-0.46 


-0.27 

-0.71 

1.82 


0.00 
0.00 
0.00 


-0.12 

-1.21 

1.45 


-0.36 

-0.14 

1.82 


-0.19 
0.82 
0.32 


-0.14 
0.32 
0.41 


-0.27 

-0.77 

1.84 


-0.45 

-0.69 

1.67 


-1.07 

-0.74 

1.20 



Table 10: Impact by hospital categories and by payment categories across APG systems 

DSH = Disproportionate Share Hospital 



-iri^U 



t)i.-*i-r^ ,, 



Description of APGs 



of hospitals. As a result of the addition of 
full packaging to the basic APG system, 
teaching hospitals with a resident-to- 
bedratio greater than 0.25 have a 3.42 
percent increase relative to the basic APG 
system. Urban hospitals over 500 beds, 
urban disproportionate share teaching 
hospitals, rural Medicare dependent hos- 
pitals, small rural hospitals and govern- 
ment hospitals experienced an increase 
between one and two percent as a result 
of adding full packaging to the basic APG 
system. There were no hospital categories 
that experienced a substantial decrease, 
except for proprietary hospitals, which 
experienced a 1.21 percent decrease. 

APG Systems 3 and 8 add one percent 
and three percent outlier payments to the 
full packaging option in APG System 7, 
respectively. The addition of outliers to the 
full packaging option of APG System 7 
does not substantially change the results, 
except that with full packaging and three 
percent outliers, mral hospitals over 100 
beds do experience a more substantial 
decrease. 

The addition of ancillary discounting 
(APG System 11) or the addition of an 
expanded window of service (APG Sys- 
tems 12 and 13) to the full packaging APG 
system with one percent outliers (APG 
System 3) does not substantially change 
the results across categories of hospitals. 

APG Systems 2 and 4 use charge 
based relative weights whereas all other 
APG systems use cost based relative 
weights. The change to charge based rel- 
ative weights has a substantial APG pay- 
ment impact across hospital categories. 
APG Systems 3 and 4 are the same 
except that APG System 3 uses cost 
based relative weights and APG System 4 
uses charge based relative weights. For 
example, for teaching hospitals with a res- 



ident to bed ratio greater than 0.25, APG 
System 3 would result in an increase rela- 
tive to the basic APG system, of 3.33 per- 
cent, while APG System 4 would result in 
a decrease of 2.84 percent. The cause of 
this relative APG payment impact is the 
low cost-to-charge ratios for ancillary 
departments. Hospitals that have the 
majority of their outpatient services as 
ancillary services would experience a 
decrease using cost based relative 
weights, since cost based ancillary APG 
relative weights are proportionately lower. 
Conversely, hospitals that have the major- 
ity of their services as direct patient care 
services (e.g., emergency room visits) 
would have an increase using cost based 
relative weights, since cost based signifi- 
cant procedure and medical APG relative 
weights are proportionately higher. To 
illustrate this impact, hospitals were cate- 
gorized based on the percent of patients 
who only received ancillary services (i.e., 
no significant procedure or medical visit). 
APG System 3 and APG System 4 are the 
same, except that APG System 3 uses 
cost based relative weights and APG Sys- 
tem 4 uses charge based relative weights. 
The difference in APG payment under 
APG System 3 and APG System 4 was 
computed and divided by the APG pay- 
ment under APG System 4. The result is 
the percent difference in APG payment 
due to cost based relative weights as 
opposed to charge based relative weights. 
Table 11 shows the results across hospi- 
tals categorized by the percent of ancillary 
only claims. 

In Table 11, the 269 hospitals having 
less than 5 percent of their claims with 
only ancillaries had an increase equal to 
6.921 percent by using cost based relative 
weights instead of charge based relative 
weights. Conversely, the 72 hospitals hav- 
ing 95 percent or more of their claims with 
only ancillaries had a decrease equal to 



The Development of a Physician Prospective Payment System for Ambulatory Care 



75 



Appendix A 



Percent 

Ancillary 

Only 



Count 
Hosp 



Percent Diff 
APG Impact 



0-5 


269 


6.921 


5-10 


50 


11.776 


10-15 


62 


14.121 


15-20 


47 


9.556 


20-25 


65 


8.580 


25-30 


82 


6.679 


30-35 


119 


3.845 


35-40 


130 


2.008 


40-45 


184 


1.807 


45-50 


268 


1.384 


50-55 


361 


0.569 


55-60 


398 


0.033 


60-65 


467 


-0.426 


65-70 


574 


-1.146 


70-75 


592 


-1.759 


75-80 


666 


-2.775 


80-85 


578 


-4.043 


85-90 


340 


-5.609 


90-95 


166 


-7.439 


95-100 


72 


-10.948 



Table 11: Percentage difference in impact between APG 

System 3 and APG System 4 by percentage of hospital 

claims that are ancillary only 

10.948 percent by using cost based rela- 
tive weights instead of charge based rela- 
tive weights. 

In summary, the alternative formulations 
of APG systems did not result in substan- 
tial differences in impact across different 
categories of hospitals. The only compo- 
nents of the APG system that caused any 
substantial variations in impact across dif- 
ferent categories of hospitals were the 
selection of charge versus cost based rel- 
ative weights and the extent of ancillary 
packaging. 

Discussion 

The statistical performance of the APGs, 
in terms of R2 was evaluated for 13 differ- 
ent APG systems. The statistical results 
provide a measure of the extent to which 



simulated APG payments for a patient cor- 
respond to the historical cost for the 
patient. In general, the statistical perfor- 
mance of the APGs is better than the sta- 
tistical performance of the inpatient DRGs. 
The evaluation of the 13 different APG 
systems resulted in the following conclu- 
sions: 

• There is virtually no difference in R2 
results for APG relative weights derived 
from charges or cost. 

• The extent of ancillary packaging does 
affect the R2 of the APGs. The R2 results 
for the simple packaging and full pack- 
aging are virtually identical. In compari- 
son to limited packaging, full packaging 
has minimal impact on R2 for significant 
procedure claims, but causes a modest 
decrease in R^ for medical claims. 

• The APG outlier policy has a significant 
impact on the R2 of the APGs. Failure to 
have any outlier policy causes a large 
reduction in R2, especially for medical 
claims. An outlier policy of having one 
percent of total APG payments associ- 
ated with outliers results in a large 
improvement in R2. A three percent out- 
lier policy further improves R2 but results 
in a substantial increase in the number 
of claims with outlier payments. 

• The addition of a 20 percent discount for 
repeated ancillaries within the same 
APG has no substantial impact on R2. 

• Expanding the ancillary packaging of 
window of service for significant proce- 
dure and medical claims beyond the 
same day has no substantial impact on 

R2. 

• Across the 13 APG systems, the only 
factors that have a substantial payment 
impact by category of hospital are the 
extent of ancillary packaging and the 
basis of the relative weights. 

Based on the above results, the recom- 
mended APG system is as follows: 



76 



Final Report 



"-'W^ 



Description of APGs 



Although the charge and cost based 
APG relative weights were highly corre- 
lated and there was virtually no differ- 
ence in R2 between the charge and cost 
based APG relative weights, the use of 
cost based relative weights is prefera- 
ble. Since the cost-to-charge ratio for 
ancillary departments tends to be lower 
than other departments, the charge 
based APG relative weights for ancillary 
services tend to be higher than the cost 
based APG relative weights. This would 
result in proportionately higher APG 
payments for ancillary services with 
charge based relative weights than with 
cost based relative weights. In particu- 
lar, it would result in an increase for hos- 
pitals that deliver ancillaries as their 
primary outpatient service. As a result of 
this bias, cost based relative weights are 
recommended. This bias is the source of 
the impact differences across hospital 
categories that would result from using 
charge based relative weights. 
Ancillary packaging provides the finan- 
cial incentives for hospital outpatient 
departments to utilize ancillary services 
efficiently. In order to provide such 
incentives, the full ancillary packaging 
option is preferable. There was a moder- 
ate decrease in R^ for medical claims 
associated with the full packaging 
option, and there was some impact 
across hospital categories as a result of 
full ancillary packaging. 
Failure to have an outlier policy would 
result in a significant decrease in R^ of 
the APGs. An outlier policy in which one 
percent of total payments are associ- 
ated with outliers is preferable. 
While the discounting of repeated ancil- 
lary services did not affect R^ the dis- 
counting of high volume, low cost 
ancillary services in the same APG 
would add complexity to the system with 
relatively few benefits. Thus, discounting 



of repeated ancillary services is not rec- 
ommended. 
• While it would be desirable to have a 
wide window of time for ancillary pack- 
aging, in order to avoid the incentive to 
have ancillaries provided on a different 
day, the current UB-92 does not identify 
the provider who ordered the ancillary 
service. Thus, the packaging of ancillar- 
ies ordered by a provider and delivered 
on a different day would impose a signif- 
icant administrative burden because 
there is no automated way to identify 
such ancillaries within the Medicare bill- 
ing system. It is recommended that the 
initial implementation of the APGs 
should have a same day window of time 
for ancillary packaging. If a wider win- 
dow of time for ancillary packaging is 
desired, the identification of the provider 
who ordered the ancillary must be 
added to the claim. 

In summary, the recommended APG 
system is APG System 3, which consists 
of cost based relative weights, full ancillary 
packaging, a one percent outlier policy, 
fifty percent discounting of each additional 
significant procedure, no repeat ancillary 
discounting and a same day window of 
time for ancillary packaging. The statistical 
performance of this APG system 
exceeded the statistical performance of 
the current inpatient DRGs. Relative to the 
basic APG system, APG System 3 does 
impact relative APG payment in some cat- 
egories of hospitals. The magnitude of the 
APG payment impact to any hospital cate- 
gory is always less than four percent. The 
APG payment impact in some hospital cat- 
egories due to APG System 3 is largely 
the result of the full ancillary packaging. 

Implementation Issues 

The APG system provides the frame- 
work for a hospital based outpatient pro- 



Tlie Development of a Physician Prospective Payment System for Ambulatory Care 



77 



Appendix A 



spective payment system. However, there 
are a series of additional issues that must 
be addressed as part of the implementa- 
tion of an APG based prospective pay- 
ment system: 

Volume of Visits 

In any visit based system, hospitals can 
increase revenue by increasing the num- 
ber of visits. Under the existing Medicare 
outpatient payment system an increase in 
visits will increase hospital revenue but not 
necessarily hospital profits. A change to 
an APG based PPS may create greater 
incentives to increase visits for certain ser- 
vices. Thus, some means of monitoring 
and controlling the number of visits should 
be implemented. 

Upcoding and Fragmentation of 
Procedure Codes 

Although the aggregation of codes into 
the APGs minimizes the opportunities for 
upcoding, hospital coding practices will 
need to be monitored. Procedure code 
fragmentation occurs when a single proce- 
dure is reported using multiple procedure 
codes. Currently, the Outpatient Code Edi- 
tor is applied by Medicare to outpatient 
claims. The Outpatient Code Editor should 
be expanded in scope to address issues 
such as procedure code fragmentation. 

Identification of Visits 

Since APGs are a visit based payment 
system, it is essential that visits can be 
unambiguously identified from the claim 
form. Batch bills, in which the dates of ser- 
vice span more than one day, present diffi- 
culties for the identification of individual 
visits. Clear rules for the reporting of the 
dates of service, the units field on the rev- 
enue trailers and the submission of batch 
bills need to be established. The result of 
these rules should be the ability to 
uniquely identify an individual visit and the 
services rendered during that visit. 



Shift of Ancillaries to Nonfiospital Settings 
as a Result of Ancillary Packaging 

If the implementation of an APG based 
PPS includes the full packaging of ancil- 
lary sen/ices, hospitals will have the finan- 
cial incentive not to provide the ancillary 
services directly but to send the patient to 
a nonhospital setting for the ancillary tests. 
The nonhospital facility could then bill 
Medicare separately for the ancillary tests. 
Thus, ancillaries ordered by hospital out- 
patient departments but delivered by non- 
hospital settings must be able to be 
identified within the claims processing sys- 
tem. In order to expand the window of ser- 
vices for ancillary packaging and to 
include within the ancillary packaging, all 
ancillaries ordered by the hospital outpa- 
tient department, the claim processing 
system must identify the provider that 
ordered an ancillary service. 

Payment of Ancillaries Ordered Outside 
the Hospital 

A large volume of the services provided 
by the ancillary department of hospitals 
are ordered by private physicians or other 
nonhospital based providers. If hospitals 
are paid on an APG basis for ancillaries 
ordered outside the hospital, and nonhos- 
pital facilities are paid on a different basis, 
then there will be a payment differential for 
the same ancillary depending on whether 
the ancillary service is delivered by a hos- 
pital or a nonhospital facility. If hospital 
ancillary departments are paid less than 
nonhospital facilities, then hospitals will be 
at a competitive disadvantage. A negative 
price differential could cause a shift of 
ancillary services out of the hospital. 

Applicability 

An outpatient PPS need not be limited to 
hospital outpatient departments but could 
also include entities that provide similar 
services. For example, ambulatory sur- 



ra 



Final Report 



..'U'lJVIff,, 



v--'-;.!!j*l>,:,. 



Description of APGs 



gery centers and free-standing radiology 
centers that provide services similar to 
hospital outpatient departments could also 
be included in an outpatient PPS. 

Consistency with Inpatient Payment 
Levels 

The increase in hospital based ambula- 
tory surgery was, in part, the result of the 
financial incentives in the Medicare pay- 
ment system. Since inpatient surgery was 
paid at the fixed DRG rate and hospital 
based ambulatory surgery was essentially 
paid at cost, there was a financial incen- 
tive to shift patients to the ambulatory set- 
ting where there were no cost controls. If 
ambulatory surgery is paid at a fixed price, 
then, depending on the payment rate for 
surgery performed on an inpatient basis, 
there may be a financial incentive to per- 
form surgery on an inpatient basis. The 
inpatient and outpatient payment rates for 
the same surgical procedure need to be 
established to provide the proper financial 
incentives. 

Computation of Prospective APG 
Payment Rates 

Historical charges or cost can be used 
to compute an initial set of APG relative 
weights. If the historical charges or cost for 
some procedures are artificially high, then 
the APG relative weights would be dispro- 
portionately high. Consideration needs to 
be given to reevaluating some of the APG 
relative weights based on actual resource 
use instead of historical cost. 

Hospital Specific Payment Adjustments 

The inpatient PPS adjusts the DRG pay- 
ment levels for hospitals based on hospital 
specific factors such as disproportionate 
share and teaching status. The APG simu- 
lations included adjustments for labor 
costs and outliers. An evaluation of 
whether additional adjustments are neces- 
sary in an APG based outpatient PPS 



needs to be performed. 
APG Update Process 

The APGs will need to be reviewed and 
updated on an annual basis to reflect 
changes in technology and practice pat- 
terns as well as the annual changes in the 
procedure and diagnosis codes. 

Conclusions 

A visit based APG prospective payment 
system can provide an effective system for 
the payment of the facility component of 
hospital based outpatient care. The APGs 
form a manageable, clinically meaningful 
set of patient classes that relate the 
attributes of patients to the resource 
demands and associated costs experi- 
enced by a hospital outpatient depart- 
ment. The components of the APG 
payment system can be configured to 
achieve specific policy objectives and to 
provide financial incentives for hospitals to 
provide efficient care. Based on the R^ 
results and relative APG payment impact 
across the alternative formulations of the 
components of an APG system, an APG 
system with cost based weights, full ancil- 
lary packaging, one percent of payments 
derived from outlier payments, 50 percent 
multiple significant procedure discounting, 
no repeat ancillary discounting and a 
same day window of time is recom- 
mended. Remaining implementation 
issues can be readily resolved and an 
APG based outpatient PPS can be imple- 
mented within a short time frame. The cur- 
rent Medicare payment system for 
outpatient services is a complex and con- 
fusing collection of payment methods, 
many of which are based on the cost in the 
hospital department providing the service. 
In an era of health care cost containment, 
a cost based payment system for hospital 
outpatient care is an anachronism which 
provides no incentives for the efficient 



The Development of a Physician Prospective Payment System for Ambulatory Care 



79 



Appendix A 

delivery of care and, therefore, must be 
replaced. An APG based outpatient pro- 
spective payment system can be a practi- 
cal and effective basis for the reform of the 
Medicare cost based outpatient payment 
system. 

References 

Averill, R., Goldfield, N., Wynn, M., 
McGuire, T., Mullin, R., Gregg, L., Bender, 
J., Design of a Prospective Payment 
Patient Classification System for Ambula- 
tory Care, Health Care Financing Review, 
Fall 1993, Vol. 15, No.1. 

Averill, R., Goldfield, N., Gregg, L., Shafir, 
B., Evaluation of a Prospective Payment 
System for Hospital-based Outpatient 
Care, Journal of Ambulatory Care Man- 
agement, 1997, 20(3), 31-48. 

Goldfield, N., Averill, R., Grant, T, Gregg, 
L., The Clinical Development of an Ambu- 
latory Classification System: Version 2.0 
Ambulatory Patient Groups, Journal of 
Ambulatory Care Management, 1997, 
20(3), 49-56. 

Hsiao, W.C, Braun, P., Yntema, D. et al.: 
Estimating Physician' Work for a 
Resource-Based-Relative-Value Scale, 
New England Journal of Medicine 
319(13):835-41, September 29, 1988. 

Relative Value Studies, Inc.: Relative Val- 
ues for Physicians, New York, McGraw- 
Hill, 1984. 

Vertrees, J., Pollatsek, J., Sheets, K., 
Stark, M., Developing an Outpatient Pro- 
spective Payment System Based on APGs 
for the Iowa Medicaid Program, Journal of 
Ambulatory Care Management, 1994, 
17(4), 82-96. 



80 



Final Report 



■'■ .'*^:. 



Description of APGs 



Appendix A 
List of Version 2.0 APGs 

SIGNIFICANT PROCEDURE AND THERAPY APGs 

APC 1 Integumentary System 

001 PHOTOCHEMOTHERAPY 

002 SUPERFICIAL NEEDLE BIOPSY AND ASPIRATION 

003 COMPLEX INCISION AND DRAINAGE 

004 SIMPLE INCISION AND DRAINAGE 

005 NAIL PROCEDURES 

006 SIMPLE DEBRIDEMENT AND DESTRUCTION 

007 COMPLEX EXCISION, BIOPSY AND DEBRIDEMENT 

008 SIMPLE EXCISION AND BIOPSY 

009 COMPLEX SKIN REPAIRS INCL INTEGUMENT GRAFTS, TRANSFER & REARRANGE 

010 SIMPLE SKIN REPAIR 

011 SIMPLE INCISION AND EXCISION OF BREAST 

012 BREAST RECONSTRUCTION AND MASTECTOMY 

APC 2 Musculoskeletal System 

021 COMPLEX MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT 

022 SIMPLE MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT 

023 COMPLEX HAND AND FOOT MUSCULOSKELETAL PROCEDURES 

024 SIMPLE HAND AND FOOT MUSCULOSKELETAL PROCEDURES 

025 ARTHROSCOPY 

026 REPLACEMENT OF CAST 

027 SPLINT, STRAPPING AND CAST REMOVAL 

028 CLOSED TREATMENT FX & DISLOCATION OF FINGER, TOE & TRUNK 

029 CLOSED TREATMENT FX & DISLOCATION EXC FINGER, TOE & TRUNK 

030 OPEN OR PERCUTANEOUS TREATMENT OF FRACTURES 

031 BONE OR JOINT MANIPULATION UNDER ANESTHESIA 

032 BUNION PROCEDURES 

033 ARTHROPLASTY 

034 HAND AND FOOT TENOTOMY 

035 ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 

APC 3 Respiratory System 

051 PULMONARY TESTS 

052 NEEDLE AND CATHETER BIOPSY ASPIRATION, LAVAGE AND INTUBATION 

053 COMPLEX ENDOSCOPY OF THE UPPER AIRWAY 

054 SIMPLE ENDOSCOPY OF THE UPPER AIRWAY 

055 ENDOSCOPY OF THE LOWER AIRWAY 
057 RESPIRATORY THERAPY 

APC 4 Cardiovascular System 

071 EXERCISE TOLERANCE TESTS 

072 ECHOCARDIOGRAPHY 

073 PHONOCARDIOGRAM 

074 CARDIAC ELECTROPHYSIOLOGIC TESTS 

075 PLACEMENT OF TRANSVENOUS CATHETERS 

076 DIAGNOSTIC CARDIAC CATHETERIZATION 



The Development of a Physician Prosfjective Payment System for Ambulatory Care 81 



Appendix A 

077 ANGIOPLASTY AND TRANSCATHETER PROCEDURES 

078 PACEMAKER INSERTION AND REPLACEMENT 

079 REMOVAL AND REVISION OF PACEMAKER AND VASCULAR DEVICE 

080 MINOR VASCULAR REPAIR AND FISTULA CONSTRUCTION 

081 SECONDARY VARICOSE VEINS AND VASCULAR INJECTION 

082 VASCULAR LIGATION 

083 RESUSCITATION AND CARDIOVERSION 

084 CARDIAC REHABILITATION 

APC 5 Hematologic, Lymphatic and Endocrine 

091 CHEMOTHERAPY BY EXTENDED INFUSION 

092 CHEMOTHERAPY EXCEPT BY EXTENDED INFUSION 

093 PHLEBOTOMY 

094 BLOOD AND BLOOD PRODUCT EXCHANGE 

095 DEEP LYMPH STRUCTURE AND THYROID PROCEDURES 

096 ALLERGY TESTS 

097 TRANSFUSION 

APC 6 Digestive System 

111 ALIMENTARY TESTS AND SIMPLE TUBE PLACEMENT 

112 ESOPHAGEAL DILATION WITHOUT ENDOSCOPY 

113 ANOSCOPY WITH BIOPSY AND DIAGNOSTIC PROCTOSIGMOIDOSCOPY 

114 PROCTOSIGMOIDOSCOPY WITH EXCISION OR BIOPSY 

115 DIAGNOSTIC UPPER Gl ENDOSCOPY OR INTUBATION 

116 THERAPEUTIC UPPER Gl ENDOSCOPY OR INTUBATION 

117 LOWER GASTROINTESTINAL ENDOSCOPY 

118 ERCP AND MISCELLANEOUS Gl ENDOSCOPY PROCEDURES 

119 HERNIA AND HYDROCELE PROCEDURES 

1 20 COMPLEX ANAL AND RECTAL PROCEDURES 

121 SIMPLE ANAL AND RECTAL PROCEDURES 

122 MISCELLANEOUS ABDOMINAL PROCEDURES 

123 COMPLEX LAPAROSCOPIC PROCEDURES 

124 SIMPLE LAPAROSCOPIC PROCEDURES 

APC 7 Urinary System 

1 31 RENAL EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY 

132 SIMPLE URINARY STUDIES AND PROCEDURES 

1 33 URINARY CATHETERIZATION AND DILATATION 

134 COMPLEX CYSTOURETHROSCOPY AND LITHOLAPAXY 

135 MODERATE CYSTOURETHROSCOPY 

136 SIMPLE CYSTOURETHROSCOPY 

1 37 COMPLEX URETHRAL PROCEDURES 

138 SIMPLE URETHRAL PROCEDURES 

139 HEMODIALYSIS 

140 PERITONEAL DIALYSIS 

APC 8 Male Genital System 

151 TESTICULAR AND EPIDIDYMAL PROCEDURES 

152 INSERTION OF PENILE PROSTHESIS 

153 COMPLEX PENILE PROCEDURES 

154 SIMPLE PENILE PROCEDURES 



04 

Final Report 



■\:Si4^'*-^i. 



Description of APGs 



1 55 PROSTATE NEEDLE AND PUNCH BIOPSY 

APC 9 Female Genital System 

171 ARTIFICIAL FERTILIZATION 

172 PROCEDURES FOR PREGNANCY AND NEONATAL CARE 

173 TREATMENT OF SPONTANEOUS ABORTION 

174 THERAPEUTIC ABORTION 

175 VAGINAL DELIVERY 

176 COMPLEX FEMALE REPRODUCTIVE PROCEDURES 

177 SIMPLE FEMALE REPRODUCTIVE PROCEDURES 

178 DILATION AND CURETTAGE 

179 HYSTEROSCOPY 

180 COLPOSCOPY 

APC 10 Nervous System 

191 EXTENDED EEG STUDIES 

192 ELECTROENCEPHALOGRAM 

193 ELECTROCONVULSIVE THERAPY 

194 NERVE AND MUSCLE TESTS 

195 NERVOUS SYSTEM INJECTIONS, STIMULATIONS OR CRANIAL TAP 

196 REVISION AND REMOVAL OF NEUROLOGICAL DEVICE 

197 NEUROSTIMULATOR AND VENTRICULAR SHUNT IMPLANTATION 

198 NERVE REPAIR AND DESTRUCTION 

199 SPINAL TAP 

APC 11 Eye and Ocular Adnexa 

211 MINOR OPHTHALMOLOGICAL TESTS AND PROCEDURES 

212 FITTING OF CONTACT LENSES 

213 LASER EYE PROCEDURES 

214 CATARACT PROCEDURES 

215 COMPLEX ANTERIOR SEGMENT EYE PROCEDURES 

216 MODERATE ANTERIOR SEGMENT EYE PROCEDURES 

217 SIMPLE ANTERIOR SEGMENT EYE PROCEDURES 

218 COMPLEX POSTERIOR SEGMENT EYE PROCEDURES 

219 SIMPLE POSTERIOR SEGMENT EYE PROCEDURES 

220 STRABISMUS AND MUSCLE EYE PROCEDURES 

221 COMPLEX REPAIR AND PLASTIC PROCEDURES OF EYE 

222 SIMPLE REPAIR AND PLASTIC PROCEDURES OF EYE 

223 VITRECTOMY 

APC 12 Facial, Ear, Nose, Mouth and Throat 

231 COCHLEAR DEVICE IMPLANTATION 

232 OTORHINOLARYNGOLOGIC FUNCTION TESTS 

233 NASAL CAUTERIZATION AND PACKING 

234 COMPLEX FACIAL AND ENT PROCEDURES 

235 SIMPLE FACIAL AND ENT PROCEDURES 

236 TONSIL AND ADENOID PROCEDURES 

237 SIMPLE AUDIOMETRY 



The Development of a Physician Prospective Payment System for Ambulatory Care 83 



Appendix A 

APC 13 Therapeutic and Other Significant Radiological Procedures 

251 THERAPEUTIC NUCLEAR MEDICINE 

252 RADIATION THERAPY AND HYPERTHERMIA 

253 VASCULAR RADIOLOGY EXCEPT FOR VENOGRAPHY OF EXTREMITY 

254 MYELOGRAPHY 

255 MISCELLANEOUS RADIOLOGICAL PROCEDURES WITH CONTRAST 

APC 14 Physical Medicine and Rehabilitation 

271 OCCUPATIONAL THERAPY 

272 PHYSICAL THERAPY 

273 SPEECH THERAPY 

APC 15 IVIental Illness and Substance Abuse Therapies 

281 NEUROPSYCHOLOGICAL TESTING 

282 FULL DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE 

283 FULL DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 

284 HALF DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE 

285 HALF DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 

286 COUNSELLING OR INDIVIDUAL BRIEF PSYCHOTHERAPY 

287 INDIVIDUAL COMPREHENSIVE PSYCHOTHERAPY 

288 FAMILY PSYCHOTHERAPY 

289 GROUP PSYCHOTHERAPY 

ANCILLARY SERVICES APGs 

APC 16 Radiology 

301 COMPLEX DIAGNOSTIC NUCLEAR MEDICINE 

302 INTERMEDIATE DIAGNOSTIC NUCLEAR MEDICINE 

303 SIMPLE DIAGNOSTIC NUCLEAR MEDICINE 

304 OBSTETRICAL ULTRASOUND 

305 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL 

306 MAGNETIC RESONANCE IMAGING 

307 COMPUTERIZED AXIAL TOMOGRAPHY 

308 A MAMMOGRAPHY 

309 DIGESTIVE RADIOLOGY 

310 PLAIN FILM 

311 THERAPEUTIC RADIATION TREATMENT PREPARATION 

APC 17 Anesthesia 
321 ANESTHESIA 

APC 18 Pathology 

331 COMPLEX PATHOLOGY 

332 SIMPLE PATHOLOGY 

333 PAP SMEARS 

APC 19 Laboratory 

341 BLOOD AND TISSUE TYPING 

342 COMPLEX IMMUNOLOGY TESTS 

343 SIMPLE IMMUNOLOGY TESTS 

344 COMPLEX MICROBIOLOGY TESTS 

345 SIMPLE MICROBIOLOGY TESTS 



84 

Final Report 



Description of APGs 



346 COMPLEX ENDOCRINOLOGY TESTS 

347 SIMPLE ENDOCRINOLOGY TESTS 

348 COMPLEX CHEMISTRY TESTS 

349 SIMPLE CHEMISTRY TESTS 

350 BASIC CHEMISTRY TESTS 

351 MULTICHANNEL CHEMISTRY TESTS 

352 ORGAN OR DISEASE ORIENTED PANELS 

353 TOXICOLOGY TESTS 

354 THERAPEUTIC DRUG MONITORING 

355 COMPLEX CLOTTING TESTS 

356 SIMPLE CLOTTING TESTS 

357 COMPLEX HEMATOLOGY TESTS 

358 SIMPLE HEMATOLOGY TESTS 

359 URINALYSIS 

360 BLOOD AND URINE DIPSTICK TESTS 

APC 20 Other Ancillary Tests and Procedures 

371 SIMPLE PULMONARY FUNCTION TESTS 

372 INFUSION THERAPY EXCEPT CHEMOTHERAPY 

373 CARDIOGRAM 

374 COMPLEX IMMUNIZATION 

375 MODERATE IMMUNIZATION 

376 SIMPLE IMMUNIZATION AND ALLERGY IMMUNOTHERAPY 

377 MINOR REPRODUCTIVE PROCEDURES 

378 MINOR CARDIAC AND VASCULAR TESTS 

379 MINOR OPHTHALMOLOGICAL INJECTION, SCRAPING AND TESTS 

380 PACEMAKER ANALYSIS 

381 TUBE CHANGE 

382 PROVISION OF VISION AIDS 

383 INTRODUCTION OF NEEDLE AND CATHETER 

384 DRESSINGS AND OTHER MINOR PROCEDURES 

385 OTHER MISCELANEOUS ANCILLARY PROCEDURES 

386 BIOFEEDBACK AND OTHER TRAINING 

APC 21 Chemotherapy Drugs 

391 CLASS ONE CHEMOTHERAPY DRUGS 

392 CLASS TWO CHEMOTHERAPY DRUGS 

393 CLASS THREE CHEMOTHERAPY DRUGS 

394 CLASS FOUR CHEMOTHERAPY DRUGS 

395 CLASS FIVE CHEMOTHERAPY DRUGS 

APC 22 Ancillary Mental Illness and Substance Abuse Services 

411 PSYCHOTROPIC MEDICATION MANAGEMENT 

412 ACTIVITY THERAPY 

APC 23 Incidental Procedures and Services 

421 INCIDENTAL TO MEDICAL, SIGNIFICANT PROCEDURE OR THERAPY VISIT 

422 MEDICAL VISIT INDICATOR 

The Development of a Physician Prospective Payment System for Ambulatory Care 85 



Appendix A 

MEDICAL APGs 

APC 24 Malignancy 

431 HEMATOLOGICAL MALIGNANCY 

432 PROSTATIC MALIGNANCY 

433 LUNG MALIGNANCY 

434 BREAST MALIGNANCIES 

435 Gl MALIGNANCIES 

436 SKIN MALIGNANCY 

437 OTHER MALIGNANCIES 

APC 25 Poisoning 

451 POISONING 

APC 26 Trauma 

461 HEAD AND SPINE INJURY 

462 MINOR SKIN AND SOFT TISSUE INJURIES EXCEPT BURNS 

463 SKIN AND SOFT TISSUE INJURIES EXCEPT BURNS 

464 FRACTURE, DISLOCATION AND SPRAIN 

465 BURNS 

466 OTHER INJURIES 

APC 27 Neonate 

481 NEONATE AND CONGENITAL ANOMALY 

APC 28 Pregnancy 

491 ROUTINE PRENATAL CARE 

492 MATERNAL ANTEPARTUM COMPLICATION 

493 ROUTINE POSTPARTUM CARE 

494 MATERNAL POSTPARTUM COMPLICATION 

APC 29 Infectious Diseases 

501 COMPLEX INFECTIOUS DISEASE 

502 MISCELLANEOUS INFECTIOUS DISEASES 

503 INFECTIOUS DISEASES OF GENITAL ORGANS 

APC 30 Nervous System Diseases 

51 1 TIA, CVA AND OTHER CEREBROVASCULAR EVENTS 

512 HEADACHE 

513 EPILEPSY 

51 4 NON TRAUMATIC LOSS OF CONSCIOUSNESS 

51 5 OTHER DISEASES OF THE NERVOUS SYSTEM 

APC 31 Eye Diseases 

531 CATARACTS 

532 REFRACTION DISORDER 

533 CONJUNCTIVITIS AND OTHER SIMPLE EXTERNAL EYE INFLAMMATION 

534 EYE DISEASES EXCEPT CATARACT REFRACTION DISORDER & CONJUNCTIVITIS 

APC 32 Ear, Nose, Mouth and Throat Diseases 

541 DENTAL DISEASE 

542 INFLUENZA, URI AND ENT INFECTIONS 



86 

Final Report 



Description of APGs 



543 HEARING LOSS 

544 OTHER COMPLEX EAR, NOSE, THROAT AND MOUTH DISEASES 

545 OTHER SIMPLE EAR, NOSE, THROAT AND MOUTH DISEASES 

APC 33 Respiratory System Diseases 

561 EMPHYSEMA, CHRONIC BRONCHITIS, AND ASTHMA 

562 PNEUMONIA 

563 COMPLEX RESPIRATORY DIS EXC EMPHYSEMA, CHR BRONCHITIS & ASTHMA 

564 SIMPLE RESPIRATORY DIS EXC EMPHYSEMA, CHR BRONCHITIS & ASTHMA 

APC 34 Cardiovascular System Diseases 

571 CONGESTIVE HEART FAILURE AND ISCHEMIC HEART DISEASE 

572 HYPERTENSION 

573 CHEST PAIN W CARDIAC ENZYMES TO RULE OUT MYOCARDIAL INFARCT 

574 CHEST PAIN WO CARDIAC ENZYMES TO RULE OUT MYOCARDIAL INFARCT 

575 SIMPLE CARDIOVASCULAR DIS EXC CHF, ISCHEMIC HEART DIS & HYPERTN 

576 COMPLEX CARDIOVASCULAR DIS EXC CHF, ISCHEMIC HEART DIS & HYPERTN 

APC 35 Digestive System Diseases 

591 NONINFECTIOUS GASTROENTERITIS 

592 ULCERS, GASTRITIS AND ESOPHAGITIS 

593 HEPATOBILIARY DISEASE 

594 HERNIA 

595 HEMORRHOIDS AND OTHER ANAL-RECTAL DISEASES 

596 OTHER COMPLEX GASTROINTESTINAL DISEASES 

597 OTHER SIMPLE GASTROINTESTINAL DISEASES 

APC 36 Major Signs, Symptoms and Findings 

611 MAJOR SIGNS, SYMPTOMS AND FINDINGS 

APC 37 Musculoslceletal Diseases 

621 BACK DISORDERS 

622 COMPLEX MUSCULOSKELETAL DISEASES EXCEPT BACK DISORDERS 

623 SIMPLE MUSCULOSKELETAL DISEASES EXCEPT BACK DISORDERS 

APC 38 Skin and Breast Diseases 

631 DISEASE OF NAILS 

632 CHRONIC SKIN ULCER 

633 CELLULITIS, IMPETIGO AND LYMPHANGITIS 

634 BREAST DISEASES 

635 SKIN DISEASES 

APC 39 Endocrine, Nutritional and Metabolic Diseases 

651 DIABETES 

652 COMPLEX ENDOCRINE,NUTRIT & METABOLIC DiS EXC DIABETES & OBESITY 

653 SIMPLE ENDOCRINE, NUTRITIONAL & METABLIC DISEASE EXC DIABETES 

654 FLUID AND ELECTROLYTE DISORDERS 

APC 40 Kidney and Urinary Tract Diseases 

661 URINARY TRACT INFECTION 

662 RENAL FAILURE 

663 COMPLEX URINARY DIS EXC URINARY TRACT INFECTN & RENAL FAILURE 

The Development of a Physician Prospective Payment System for Ambulatory Care 87 



Appendix A 

664 SIMPLE URINARY DIS EXC URINARY 
TRACT INFECTN & RENAL FAILURE 

APC 41 Male Genital System Diseases 

671 BENIGN PROSTATIC HYPERTROPHY 

672 MALE REPRODUCTIVE DISEASES 
EXCEPT BENIGN PROSTATIC 
HYPERTROPHY 

APC 42 Female Genital System Diseases 

681 GYNECOLOGIC DISEASES 

APC 43 Immunologic and Hematologic 
Diseases 

691 HIV INFECTION 

692 ANEMIA 

693 OTHER COMPLEX IMMUNOLOGIC AND 
HEMATOLOGIC DISEASE 

694 OTHER SIMPLE IMMUNOLOGIC AND 
HEMATOLOGIC DISEASE 

APC 44 Well Care, Administrative 

701 ADULT MEDICAL EXAMINATION 

702 WELL CHILD CARE 

703 CONTRACEPTION AND PROCREATIVE 
MANAGEMENT 

704 AFTERCARE 

705 NONSPECIFIC SIGNS & SYMPTOMS & 
OTH CONTACTS W HEALTH SVCS 

APC 45 Unl(nown Cause of Mortality 

721 UNKNOWN CAUSE OF MORTALITY 

APC 46 Error 

992 INVALID PROCEDURE CODE 

993 INPATIENT PROCEDURE 

994 AUTOPSY SERVICES 

995 NON COVERED CARE SETTINGS AND 
SERVICES 

996 INVALID RVDX CODE 

997 ECODE CANNOT BE USED AS RVDX 

998 UNACCEPTABLE RVDX, REQUIRES 
PROCEDURE 

999 UNGROUPABLE 



88 



Final Report 



APPENDIX B 



Map of Physician Specialty Codes to 
Specialty Categories 



The Development of a Physician Prospective Payment System for Ambulatory Care 



APPENDIX B 



SPECIALTY GROUP 


SPECIALTY 


Primary Care 


GENERAL PRACTICE 


Primary Care 


FAMILY PRACTICE 


Primary Care 


INTERNAL IVIEDICINE 


Primary Care 


PEDIATRIC MEDICINE 


General Surgery 


GENERAL SURGERY 


Genera] Suigery 


ALLERGY/IMMUNOLOGY 


General Surgery 


CARDIOLOGY 


General Surgery 


DERMATOLOGY 


General Surgery 


GASTROENTEROLOGY 


General Surgery 


NEUROLOGY 


General Surgery 


"OPHTHALMOLOGY. OTOLOGY, LARYNGOLOGY.RHINOLOGY (OSTEPATHS 
ONLY)" 


Genera] Surgery 


"PERIPHERAL VASCULAR DISEASE, MEDICAL OR SURGICAL (OSTEOPATHS 
ONLY) - DISCONTINUED 5/92" 


General Surgery 


PHYSICAL MEDICINE AND REHABILITATION 


General Surgery 


PULMONARY DISEASE 


General Surgery 


GERIATRIC MEDICINE 


General Surgery 


NEPHROLOGY 


General Surgery 


INFECTIOUS DISEASE 


General Surgery 


ENDOCRINOLOGY (EFF 5/92) 


General Surgery 


RHEUMATOLOGY (EFF 5/92) 


General Surgery 


PERIPHERAL VASCULAR DISEASE 


General Surgery 


CRITICAL CARE (INTENSIVISTS) 


Genera] Surgery 


HEMATOLOGY (EFF 5/92) 


General Surgery 


PREVENTIVE MEDICINE (EFF 5/92) 


General Surgery 


EMERGENCY MEDICINE (EFF 5/92) 


Surgical Specialties 


OTOL ARYNGOLOG Y 


Surgical Specialties 


NEUROSURGERY 


Surgical Specialties 


OPHTHALMOLOGY 


Surgical Specialties 


ORTHOPEDIC SURGERY 


Surgical Specialties 


PLASTIC AND RECONSTRUCTIVE SURGERY 


Surgical Specialties 


COLORECTAL SURGERY (FORMERLY PROCTOLOGY) 


Surgical Specialties 


THORACIC SURGERY 


Surgical Specialties 


UROLOGY 


Surgical Specialties 


HAND SURGERY 


Surgical Specialties 


VASCULAR SURGERY (EFF 5/92) 


Surgical Specialties 


CARDIAC SURGERY (EFF 5/92) 


Surgical Specialties 


MAXILLOFACIAL SURGERY (EFF 5/92) 


Surgical Specialties 


INTERVENTIONAL RADIOLOGY (EFF 5/92) 


Anesthesiology 


ANESTHESIOLOGY 


Obstetrics and Gynecology 


GYNECOLOGY (OSTEOPATHS ONLY) 


Obstetrics and Gynecology 


OBSTETRICS (OSTEOPATHS ONLY) 



90 



Final Report 



i-XW^ 



Map of Physician Specialty Codes to Specialty Categories 



SPECIALTY GROUP 


SPECIALTY 


Obstetrics and Gynecology 


OBSTETRICS/GYNECOLOGY 


Oncology 


HEMATOLOGY/ONCOLOGY (EFF 5/92) 


Oncology 


MEDICAL ONCOLOGY (EFF 5/92) 


Oncology 


SURGICAL ONCOLOGY (EFF 5/92) 


Oncology 


GYNECOLOGIST/ONCOLOGIST (EFF 10/94) 


Psychiatry and Psychology 


PSYCHIATRY 


Psychiatry and Psychology 


"PSYCHIATRY, NEUROLOGY (OSTEOPATHS ONLY) - DISCONTINUED 5/92" 


Psychiatry and Psychology 


PSYCHOLOGIST (BILLING INDEPENDENTLY) 


Psychiatry and Psychology 


CLINICAL PSYCHOLOGIST 


Psychiatry and Psychology 


ADDICTION MEDICINE (EFF 5/92) 


Psychiatry and Psychology 


NEUROPSYCHIATRY (EFF 5/92) 


Radiology 


DIAGNOSTIC RADIOLOGY 


Radiology 


"ROENTGENOLOGY. RADIOLOGY (OSTEOPATHS ONLY) DISCONTINUED 5/92" 


Radiation Therapy 


RADIATION THERAPY (OSTEOPATHS ONLY) DISCONTINUED 5/92 


Radiation Therapy 


NUCLEAR MEDICINE 


Radiation Therapy 


RADIATION ONCOLOGY (EFF 5/92) 


Non-physician Professional Services 


OSTEOPATHIC MANIPULATIVE THERAPY 


Non-physician Professional Services 


ORAL SURGERY (DENTISTS ONLY) 


Non-physician Professional Services 


"PATHOLOGIC ANATOMY. CUNICALPATHOLOGY (OSTEOPATHS ONLY) - DISCON- 
TINUED 5/92" 


Non-physician Professional Services 


PATHOLOGY 


Non-physician Professional Services 


CHIROPRACTIC 


Non-physician Professional Services 


OPTOMETRY (REVISED 10/93 TO MEAN OPTOMETRIST) 


Non-physician Professional Services 


CERTIFIED NURSE MIDWIFE (EFF 1/87) 


Non-physician Professioneil Services 


"CRNA. ANESTHESIA ASSISTANT- 


Non-physician Professional Services 


PODIATRY 


Non-physician Professional Services 


NURSE PRACTITIONER 


Non-physician Professional Services 


INDIVIDUAL CERTIFIED ORTHOTIST 


Non-physician Professional Services 


INDIVIDUAL CERTIFIED PROSTHETIST 


Non-physician Professional Services 


INDIVIDUAL CERTIFIED PROSTHETIST-ORTHOTIST 


Non-physician Professional Services 


AUDIOLOGIST (BILLING INDEPENDENTLY) 


Non-physician Professional Services 


PHYSICAL THERAPIST (INDEPENDENTLY PRACTICING) 


Non-physician Professional Services 


OCCUPATIONAL THERAPIST (INDEPENDENTLY PRACTICING) 


Non-physician Professional Services 


LICENSED CLINICAL SOCIAL WORKER 


Non-physician Professional Services 


CERTIFIED CLINICAL NURSE SPECIALIST 


Non-physician Professional Services 


OPTICIAN (EFF 10/93) 


Non-physician Professional Services 


PHYSICIAN ASSISTANT (EFF 5/92) 


Other Medical Services and Supplies 


CARRIER WIDE 


Other Medical Services and Supplies 


MAMMOGRAPHY SCREENING CENTER 


Other Medical Services and Supplies 


AMBULATORY SURGICAL CENTER 


Other Medical Services and Supplies 


MEDICAL SUPPLY COMPANY WITH CERTIFIED ORTHOTIST 


Other Medical Services and Supplies 


MEDICAL SUPPLY COMPANY WITH CERTIFIED PROSTHETIST 


Other Medical Services and Supplies 


MEDICAL SUPPLY COMPANY WITH CERTIFIED PROSTHETIST-ORTHOTIST 



The Development of a Physician Prospective Payment System for Ambulatory Care 



91 



APPENDIX B 



SPECIALTY GROUP 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



SPECIALTY 



MEDICAL SUPPLY COMPANY NOT INCLUDED IN 51, 52. OR 53" 



"INDIVIDUALS NOT INCLUDED IN 55. 56. OR 57 - MEDICAL SUPPLY COMPANY 
WITH PHARMACIST" 



AMBULANCE SERVICE SUPPLIER. E.G., 



PUBLIC HEALTH OR WELFARE AGENCIES 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



Other Medical Services and Supplies 



VOLUNTARY HEALTH OR CHARITABLE AGENCY 



PORTABLE X-RAY SUPPLIER 



CLINICAL LABORATORY (BILLING INDEPENDENTLY) 



MULTISPECIALTY CLINIC OR GROUP PRACTICE 



DIAGNOSTIC X-RAY (GPPP) (OBSOLETE AFTER 5/92 



DIAGNOSTIC LABORATORY (GPPP) (OBSOLETE AFTER 5/92) 



PHYSIOTHERAPY (GPPP) (NOT TO BE ASSIGNED AFTER 5/92) 



OCCUPATIONAL THERAPY (GPPP) NOT ASSIGNED AFTER 5/92 



OTHER MEDICAL CARE (GPPP) (NOT TO BE ASSIGNED AFTER 5/92) 



ALL OTHER SUPPLIERS (E.G. DRUG AND 



UNKNOWN SUPPLIER/PROVIDER SPECIALTY 



INDEPENDENT PHYSIOLOGICAL LAB 



UNKNOWN PHYSICIAN SPECIALTY 



HOSPITAL (EFF 10/93) 



SNF (EFF 10/93) 



INTERMEDIATE CARE NURSING FACILITY 



NURSING FACILITY OTHER (EFF 10/93)" 



HHA (EFF 10/93) 



PHARMACY (EFF 10/93) 



MEDICAL SUPPLY COMPANY WITH RESPIRATORY THERAPIST 



DEPARTMENT STORE (FOR DMERC USE: 



GROCERY STORE (FOR DMERC USE: 



92 



Final Report 



APPENDIX C 



Summary of Difference Between 
Version 2.0 APGs and PCGs 



The Development of a Physician Prospective Payment System for Ambulatory Care 93 



APPENDIX C 



PCGs were commissioned for the purpose of developing a prospective 
payment system (PPS) for outpatient physician and health professional 
payments. The starting point for PCG development was APG Version 2. 
Though very similar in design and execution, there are a number of 
differences between the two systems. Some of the differences are the 
inevitable result of changes in code definitions such as the addition and 
deletion of codes. Other are more clinical and conceptual in nature. The 
following general clinical considerations entered into the process of changing 
version 2 of APGs into to PCGs: 

•Services that were previously packaged under APGs but which constitute 
distinct physician services were assigned to separate PCGs. For example, 
the single APG for anesthesia was split into to three PCGs and changed 
from an ancillary to a significant procedure. 

• Ancillary services which often are associated with a visit to a physician's 
office were identified and placed into separate PCGs. Thus, there are 
several new ancillary PCGs such as PCG 362, Basic Chemistry Tests. In 
an effort to take into account physician complexity, careful attention was 
paid to differences in the amount of physician time and effort. ENT 
procedures, for example, were split from two groups into three groups. 
Where appropriate third and fourth levels of complexity were added to 
PCGs. 

• Differences in the level of complexity between groups (PCGs) of similar 
procedures is no longer explicitly identified by name. The terms simple, 
moderate, complex and extreme were replaced by levels of procedures 
(i.e.. Level I, II, III, and IV) at the suggestion of HCFA staff. 

• Codes for radiology supervision and inteipretation codes which were 
classified by body system and not in radiology APGs were moved into 
radiology PCGs. 

• There was a careful reexamination of codes to be certain that only 
inpatient procedures were categorized in PCG 993 (Inpatient Services). 
Procedures which could be performed on either an inpatient or outpatient 
basis were assigned a PCG. Where appropriate codes were reassigned 
from the inpatient only PCG to the appropriate PCG. 

• In recognition of the broad scope of services which might be included 
under outpatient PPS, PCGs were created to support the expansion of 
PCGs to encompass services beyond the immediate scope of the analysis. 
For instance, because of the inclusion of dental services by many 
Medicaid payers a set of dental PCGs was added. PCGs were also created 
for home care and ESRD (end stage renal disease). 

As a consequence of these general considerations, the number of groupings 
increased from 299 to 410. The following provides a summary of the clinical 
rationale of the grouping changes: 



94 



Final Report 



rC^'Alf:. 



Summary of Difference Between Version 2.0 APGs and PCGs 



o 



Skin and Integumentary PCGs 

Three types of changes were applied to the Skin and Integumentary APGs 
apart from the changes necessitated by code changes such as the addition or 
deletion of codes. First, several codes were moved to PCGs more consistent 
with the anatomic site of the procedure. In one instance, 65270 (Repair Of 
Laceration; Conjunctiva, With Or Without Nonperforating Laceration Sclera, 
Direct Closure) was moved out of skin procedures and into eye procedures. 
Second, several codes related to the placement of needles were moved to 
PCGs more in line with their intended purpose. For example, 76096 
(Preoperative Placement Of Needle Localization Wire, Breast, Radiological 
Supervision And Interpretation), was moved from the skin area where it had 
been linked to other needle procedures to PCG 283 where it was placed with 
other radiology procedures. The greatest number of changes between the two 
systems, however, reflected the greater sensitivity of PCGs to differences in 
complexity of physician work. Thus, the skin debridement APG was divided 
into two PCGs. The axis of classification was largely the size of the area to be 
debrided. For example, 11300 (shaving of epidermal lesion, single, diameter 
0.5 cm or less) was placed in PCG 7, Level I Skin Debridement And 
Destruction, while 11303 (shaving of epidermal or dermal lesions, diameter 
over 2.0 cm) was placed in PCG 8, Level n Skin Debridement And 
Destruction. 



PCG 25: Breast Reconstruction and Mastectomy 

This PCG constimtes the most complex of the PCGs in the Breast MDC. Most 
of the codes in this PCG come from APG 28 (Breast Reconstruction and 
Mastectomy). A few of the less complex procedures were taken from this 
PCG and placed into Level n Breast Procedures described below. 



PCG 26 and PCG 27: Level I and Level II Breast Procedures 

Several of the less complex procedures that had been in APG 28 (now PCG 
25) were placed into an intermediate and new PCG (27) termed Level II 
Breast Procedures. For instance, 19140 (mastectomy for gynecomastia) was 
placed into Level LI Breast Procedures while 19180 (mastectomy, simple, 
complete) was kept in the more complex PCG 25 (Breast Reconstruction and 
Mastectomy). 



PCG 30-32, Level i, Level II, Level III Musculoskeletal 
Procedures Excluding Hand and Foot. 

In essence, the two APGs were further arranged into three PCGs in an effort 
to provide greater recognition of resource consumption of physician services. 
Procedures such as bone grafts are in level III (e.g., 20962); many excisions 
are in level II (e.g., 21600, excision of rib, partial); and smaller procedures 



The Development of a Physician Prospective Payment System for Ambulatory Care 95 



APPENDIX C 



such as tendon repairs (e.g., 25272, repair, tendon on muscle, extensor, 
forearm and/or wrist). 



PCG 33-35, Level I, Level II, Level III Hand and Foot 
Procedures 

Similar to PCGs 30-32, these three hand and foot procedures were originally 
two APGs. These two APGs were split into three PCGs to take into account 
the complexities of physician resource consumption. Thus, flaps were largely 
placed into Level HI (e.g., 20972, free osteocutaneous flap with microvascular 
anastomosis); relatively complex repairs such as fasciotomy or synovectomies 
were placed into Level 11; and relatively simple repairs such as phalangeal 
joint arthrotomies (e.g., 26100) were placed into Level I. 

PCG 36, Arthroscopy 

This PCG was virtually unchanged from APG 25 of the same name. 

PCG 37-39; Application of Casts; Splint, Strapping and Cast 
Removal; Unna Boot Application 

These three PCGs largely derive from one APG, 58, Splint, Strapping and 
Cast Removal. From a physician time perspective, significantly more effort is 
consumed in the application of a cast as compared to the application of an 
Unna Boot, which is often performed by an allied health professional. The 
Unna Boot Application was also classified as a professional ancillary allowing 
it to be performed in conjunction with a medical visit. 

PCG 40-42 Closed Treatment of Fractures and Dislocations 
of Hand, Foot, and Trunk; Closed Treatment of Fractures 
with Manipulation Except Hand, Foot and Trunk.; Closed 
Treatment of Fractures without Manipulation Except Hand, 
Foot and Trunk 

These three PCGs originate from two APGs pertaining to the closed treatment 
of fractures. The construction of the three PCGs is a significant deparmre 
from prior classification efforts of ambulatory significant procedures. 
Manipulation of the fracture became a defining node in the axis of 
classification. Several physicians participating in the project believed it to be 
important to reflect differences in resource based relative values of services 
between treatment of closed fractures with manipulation and those performed 
without manipulation. 



^ Final Report 



Summary of Difference Between Version 2.0 APGs and PCGs 



PCG 43: Open or Percutaneous Treatment of Fractures 

This PCG was unchanged from APG 30 of the same name, in the sense that no 
codes were taken out. However, a number of codes were moved into this PCG 
from APG 31 (Bone or Joint Manipulation under Anesthesia). APG 31 was 
eliminated as several physicians believed that anesthesia should not be an axis 
of classification. 



PCG 44: Bunion Procedures 

This PCG was virtually unchanged from APG 67, Bunion Procedures, with 
the exception of code 28110, which involves a small bunion or bunionette. 
Due to the resource consumption involved in this procedure, this particular 
code was placed into PCG 33Xevel 1, Hand and Foot Procedures. 



PCGs 45-46; Arthroplasty without Prosthesis; Arthroplasty 
with Prosthesis 

These two PCGs were derived from one APG 33 (Arthroplasty). This APG 
was divided into two PCGs to reflect those procedures which were done with 
and without a prosthesis. When constructing a system for physician payment 
it is important to distinguish those aspects of a visit attributable to physician 
services from those which are fixed, such as a prosthesis. This was done for 
these two PCGs. In addition four codes (27524, 27766, 27792, and 27814) 
were moved from APG 993 (Inpatient Procedure) to PCG 43 to reflect the fact 
that these procedures may be done in the outpatient setting. 



PCG 47, Hand and Foot Tenotomy; PCG 48, Arthrocentesis 

These two PCGs were not changed from APGs 34 and 35 of the same name. 



PCG 55-57; Level I, Level II, and Level III Pulmonary 
Function Tests. 

These three PCGs were constructed from a single APG. The distinguishing 
variables pertained to time involved in the performance of the test and the 
expense of the machine that was involved. For example, 94760 (pulse 
oximetry) a very simple test, was placed in Level I Pulmonary Function Tests, 
while 94772 (24 hour continuous recording) was placed in Level III 
Pulmonary Function Tests. PCGs 55 and 56, Level I and Level II Pulmonary 
Function Tests, were classified as professional ancillaries to allow their use in 
the context of a medical visit. 



The Development of a Physician Prospective Payment System for Ambulatory Care 97 



APPENDIX C 



PCG 58 Needle and Catheter Biopsy, Aspiration, Lavage and 
Intubation 

This PCG was virtually the same as APG 52 of the same name. A few codes 
were removed from this APG and placed into other PCGs. For example, a 
very simple procedure, 31720 (catheter aspiration, nasotracheal), was placed 
into another simpler PCG(233), Level 1 Facial and ENT Procedures. 



PCGs 59-61 Levels I, II, and III Endoscopy of the Upper 
Airway. 

These three PCGs were derived from two APGs. The distinguishing 
characteristic of the additional PCG is its diagnostic nature and the fact that it 
is an extremely simple endoscopy to perform, from an anatomic perspective. 



PCG 62 Bronchoscopy 

This PCG was largely derived from APG 84, Complex Endoscopy of the 
Lower Airway. A small number of simpler bronchoscopic type codes such as 
31710, catheterization for bronchography was placed into a PCG requiring 
fewer resources (PCG 58). 



PCG 63: Respiratory Therapy 

This PCG was unchanged from the previous APG of the same name. 

PCG 70: ECG 

This was unchanged in terms of content from the previous APG of the same 
name. However, it was changed from an ancillary procedure under APGs to a 
professional ancillary under PCGs. 

PCGs 71-89. Various Cardiac PCGs 

These PCGs were virtually unchanged from APGs of a similar name. Several 
codes were moved to better reflect the character of the procedure. For 
example, 36488, placement of central venous catheter, was removed from 
PCG 77, Transcatheter Procedures, and placed into a more appropriate, and 
new PCG, Central Venous Catheter Placement. Another type of change 
pertained to the use of supervision and interpretation codes for radiology. For 
example, 71090 (insertion pacemaker, fluoroscopy and radiography, 
radiological supervision and interpretation) was moved from a cardiac APG to 
a radiological PCG (PCG 260, Fluoroscopy). In many ways, this latter change 
moved PCG construction back to APG version L 



98 



Final Report 



Summary of Difference Between Version 2.0 APGs and PCGs 



PCG 90, 91 Level I and Level II Venipuncture and Blood 
Collection 

Most of the codes in these PCG 90 and 91 came from APG 383, Introduction 
of Needle and Catheter. Two codes, 36420 and 36425 (venipuncture, cutdown; 
under age 1 year and older than age 1) came from APG 3, Complex Incision 
and Drainage. The simplest and by far the most frequent venipunctures 
(36415 and GOOOl), which are routinely done in a physician's office, are 
distinguished from all other venipuncture and blood collection efforts and 
classified as level I. The other, more complex venipunctures were classified as 
level II. Both groups have been reclassified from an ancillary to a professional 
ancillary. 

PCGs 95-98 Chemotherapy PCGs 

These four PCGs were derived from 2 APGs, with a number of additional 
codes coming from other body systems, notably the genitourinary system. 
The two new PCGs included one involving chemotherapy administered 
subcutaneously or via IM (an important procedure in a physician's office) and 
one specifically for bladder installation. The latter procedure was in the 
genitourinary APG system. These codes were removed from the latter system 
and placed into the more appropriate chemotherapy area as it reflects the 
purpose of the procedure and the particular resources consumed during the 
procedure. 

PCGs 99-106 Hematological PCGs 

The vast majority of these PCGs are essentially the same as similarly named 
APGs. Some of the simpler hematological procedures that involved surface 
skin excisions, such as 38300 or drainage of lymph node abscess, simple, was 
placed into its more anatomically correct PCG (4) within the skin and 
integumentary system MDC. The Allergy Test APG that was in the 
Hematological MDC in the APG system was split into two significant 
procedure PCGs, 328 and 329. The axis of classification was whether the visit 
was for allergy tests or the follow-up injections. Both of these PCGs are very 
much dependent on physician resource consumption. The reason for the split 
into two allergy PCGs is in part due to the difference in physician time but it is 
also due to the difference in resource consumption between tests and follow- 
up injections. 

PCG 1 1 5-1 30 Gastrointestinal MDC 

The vast majority of codes remained in their similarly named APGs. Where 
changes did occur they could be classified into the following categories: 

• A small number of new PCGs were created. Hernia procedures were split 
into two PCGs from the previous APG of a similar name. The axis of 
classification was anatomic with umbilical hernias taken out and placed 

The Development of a Physician Prospective Payment System for Ambulatory Care 99 



APPENDIX C 



into a miscellaneous GI procedure PCG. The latter PCG involved greater 
complexity as compared to simple inguinal hernia procedures. 

• Radiological supervision and interpretation codes were taken out of the 
GI system and placed into the Radiological System. 

• Several codes were moved around within similar GI procedures. Thus, the 
diagnostic vs. therapeutic distinction pertaining to colonoscopy was 
changed to Level I and Level II. Within this distinction, several codes 
were moved to better reflect resource consumption of physician services. 

• One PCG, Simple Anoscopy, was reclassified as a professional ancillary 
from a simple ancillary. 

PCGs 131-146 Genitourinary Significant Procedures 

While the content of the genitourinary procedure groups remained the 
essentially the same and the primary focus was complexity, additional weight 
was given to resource consumption resulting in some movement of codes 
between groups. In addition, some the names of the groups were changed 
significantly. 

PCG 150>155. Male Significant Procedures 

Only a small number of codes were moved from this MDC. For example, and 
similar to other already discussed PCGs, 54100 (biopsy of penis, cutaneous), 
was moved from the Male Genital Procedure APC to the Skin and 
Integumentary Procedure PPC. Also, as previously discussed, simple and 
complex penile procedures was renamed Level I and Level II Penile 
Procedures. 



PCG 160-172 Female or Gynecological Significant 
Procedures 

Several new PCGs were created in this body system and/or moved from the 
ancillary PCG section to the significant procedure section. 

A new significant procedure, PCG 160, insertion of subcutaneous 
contraceptive, was created to reflect physician resource consumption (the time 
involved for this particular procedure) in conjunction with the resources 
required in the purchase of the contraceptive itself. While the utility of this 
PCG for Medicare is clearly marginal, it was created with the needs of 
Medicaid, with its younger population, in mind. 

In addition, three miscellaneous gynecological procedures were created 
(levels I-HI) from the two miscellaneous gynecological procedures which 
existed under version 2.0 of the APGs. These were created on the basis of 
complexity of the procedures. Thus, 56405 (incision and drainage of vulva or 
perineal abscess), was placed into the simplest of the PCGs while 
colporrhaphies were placed into PCG 168, a significantly more complex PCG 



100 



Final Report 



Summary of Difference Between Version 2.0 APGs and PCGs 



requiring greater physician time and resource consumption emanating from 
the use of durable equipment. 

PCG 172, obtaining a PAP smear, was changed from an ancillary PCG to a 
professional ancillary PCG. This recognized the physician services involved 
in the performance of this procedure and the fact that patients come for an 
office visit specifically for this purpose. 



PCGs 180-201 Neurologic Significant Procedures 

Only relatively minor changes occurred within this body system when moving 
from APG 2.0 to PCGs. Of note, one new PCG was created to reflect 
differences in resource consumption that can occur with 
electroencephalograms (EEGs). Thus, two PCGs replaced the one APG that 
was present before. The axis of classification for these the more complex PCG 
is largely time with the more complex EEGs often occurring for 24 hours. 
Nerve repairs was split into two PCGs (196, 197) in virtually the same 
construction as was present in version 1.0 of the APGs. Lastly, and most 
importantly, APG 266 (Nervous System Injections, Stimulations or Cranial 
Tap) was split into its component parts. Thus, there are now PCGs for 
injections (200 and 201), Stimulations (194, 192) and Cranial Taps (198). 



PCGs 205-223 Ophthalmological Significant Procedures 

Several new PCGs were created in this MDC. The axis of classification for 
these new PCGs was complexity and resource consumption. Therefore, there 
are now four PCGs pertaining to Repair and Plastic Procedures of the Eye 
(levels I, II, in Repair and a separate PCG for Extraocular Muscle 
Procedures) where previously there were only two APGs with the same name. 
Similarly, Eye Tests and Procedures were split into two PCGs. Under APGs 
there was only one of the same name. The axis of classification was again 
complexity and extent of physician resource consumption. A completely new 
type of PCG, ophthalmologic examinations was created. This is an important 
PCG as it reflects not just physician time but also the equipment that must be 
used in this significant procedure. 



PCGs 230-240 Ear, Nose and Throat Significant Procedures 

Anatomic distinctions present in the APG structure were largely removed in 
the PCG ENT Significant Procedures. By way of illustration, APG 
distinctions between tympanostomy and tympanoplasty (both of which were 
reflected in APG names) were removed in favor of distinctions on the basis of 
levels. A professional ancillary, PCG 239, Removal of Impacted Cerumen and 
Foreign Bodies, was created from ancillaries and procedures outside of the 
ENT APGs. The latter PCG was present in version 1 .0 of the APG System. 



The Development of a Physician Prospective Payment System for Ambulatory Care 1 01 



APPENDIX C 



PCGs 245-283 Radiologic Significant Procedures 

Changes in the Radiologic Significant Procedures from version 2.0 APGs 
reflected a number of factors: 

• Changes in CRT coding. Thus, PCG 260, Fluoroscopy, was recreated (this 
class was also present in Version 1 .0 of the APGs). 

• A need to reflect physician resource consumption. For example, a 
separate PCG was created for Therapeutic Radiation Treatment Planning 
(245). This latter PCG was distinguished from Treatment Preparation 
which in turn was divided into two separate PCGs. These three radiation 

- therapy planning and preparation PCGs reflect pure physician and allied 
health professional resource consumption. They would not have been 
necessary for a payment system for the facility payment of outpatient 
departments but are necessary when needing to examine issues of 
physician payment. 

• As elsewhere, several APGs were split into finer number of groupings 
based on complexity. Seven PCGs were created for Nuclear Medicine 
when only three existed under the APG system. This was largely done on 
the basis of complexity, though planar nuclear medicine procedures were 
separated out due to the expense of the durable medical equipment. 

• Several completely new PCGs were created. PCG 282, PET scans, was 
identified as a new PCG based on changes in technology. 

It should be emphasized that many of the PCGs were unchanged from their 
similarly named APGs. Hence, the mammography PCG or obstetrical 
ultrasound PCG was the same as its similarly named APG. 

PCGs 290-315. IVIental Health PCGs 

In many respects, the mental health PCGs were not changed from their 
similarly named APGs. The following changes that did occur merit 
discussion: 

• Age distinctions were used similarly to their use in version 1.0 of the 
APGs. Consequently, PCGs 301 and 302, Brief Individual Visits For 
Thought And Personality Disorders, were split on the basis of age 
younger or older than 18. The diagnosis for these two PCGs are 
frequently very different and therefore resource consumption can be quite 
distinct over the long term. Similar distinctions were made for substance 
abuse (extended visit, PCGs 297 and 298; brief visit, PCGs 299 and 300), 
symptoms and affective disorders )PCGs 303 and 304), and observation 
for abuse, rape, and assault (PCGs 305 and 306). 

• The Senility and Mental Retardation Therapy is virtually the same as that 
used in version 1.0 of the APGs. 

• Many of the PCGs and APGs were the same. Distinctions for partial 
hospitalization remain in both the PCG and APG system. 



102 



Final Report 



• i^'r!r^i% ,^>-*v..^s.|f>^ 



Summary of Difference Between Version 2.0 APGs and PCGs 



316-320 Rehabilitation PCGs 

With one exception, these PCGs are the same as those in the similarly named 
APGs. PCG 319, Manipulation, is a subdivision of the Physical Therapy PCG. 
This was done to reflect differences in use of durable equipment in the 
Physical Therapy PCG (317) and the use of professional time in the 
Manipulation PCG (319). 



335-337 Anesthesia 

In many ways these are completely new PCGs. While there was one APG for 
anesthesia, there are now three PCGs. More importantly is that under APGs, 
anesthesia was an ancillary and as such was always packaged into the 
significant procedure APG which then automatically treated anesthesia as part 
of the procedure. Under PCGs, anesthesia is a significant procedure. This was 
done to reflect the need to distinguish different levels of physician resource 
consumption for anesthesia services. While anesthesia services are always 
packaged for hospital facility payment, this is not the case in physician 
payment where anesthesiologists are an additional visit or service. Hence, it is 
necessary to distinguish and pay separately for anesthesia services when using 
a case mix classification system for physician payment purposes. As a 
consequence, separate and distinct anesthesia PCGs were identified and 
classified based on physician resource consumption. As indicated three new 
anesthesia PCGs (335,336, and 337) were created from the single anesthesia 
APG. These are divided on the basis of complexity. Particular attention was 
paid to identifying inpatient related anesthesiology to ensure that PCGs 
contained only those procedures which could be performed on an outpatient 
basis. For example, 00540 (anesthesia for thoracotomy procedures) was 
placed in PCG 993, inpatient procedures, because this anesthesia is done for a 
procedure only done on an inpatient basis. 



341-344 Physician Evaluation and Physician Supervision 

The approach used for anesthesia was extended to physician evaluation and 
supervision services. There are significant procedures for physician 
supervision of ESRD ( PCG 341), physician provided home health care (PCG 
342), physician supervision of home health care (PCG 343) and medical 
conferences (PCG 344). 



PCG 350-403 Ancillary PCGs 

The major changes in these PCGs were the development of PCGs specifically 
to recognize services often provided in physician offices. For example, 
separate PCGs were created for Strep Test (375), Hematocrit (376), and 
Glucose (377). In addition, a new PCG was created for Pathology Services as 
many CPT codes in this area specifically pertain to services based on 
physician effort. Thus, code 89190 (nasal smear for eosinophils) is an 



The Development of a Physician Prospective Payment System for Ambulatory Care 1 03 



APPENDIX C 



example of a code in the simple pathology PCG while 88349, electron 
microscopy, scanning, is appropriately placed in the most complex pathology 
PCG. Several new PCGs were created in the ancillary section to specifically 
address services that are largely related to medical equipment or other similar 
fixed costs; PCG 401, ESRD Supphes, is an example of this type of PCG. 



PCG 492, 421-425 Incidental Procedure PCGs 

These PCGs are divided into two types: indicators of a visit to a physician or 
services provided incidentally during a visit. Code 92015, determination of 
refractive state, is in the latter type of PCG as it is incidental to, in this case, an 
ophthalmologic exam. In contrast, 99151, prolonged physician attendance, 
falls into one of the physician medical indicator PCGs. The former are 
services which are, at the discretion of the user of PCGs, available for 
packaging into other visits. The latter are used in the PCG logic which 
requires that every HCPCS has a PCG. After data are completely grouped, no 
patients are assigned to them. 



PCG 431-437 Malignancy PCGs 

Two new medical visit PCGs were created within this MDC: PCGs for GI and 
Breast. This was done to reflect the frequency of visits and the likelihood that 
in may situations these particular diagnoses would engender different types 
and amount of ancillary procedures. In turn, these latter procedures may, upon 
consideration, be appropriately packaged. 



PCG 451 Poisoning 

Except for updates of codes no change occurred in this PCG which has its 
own MDC. 



PCG 460-466 Trauma and Injury 

Two important changes occurred within this MDC. Both pertain to the 
creation of new PCGs which were subdivided from their original APGs for 
the purpose of providing better diagnostic and/or anatomic specificity. For 
example, APG 632, Bums and Skin and Soft Tissue Injury was spbt into two 
PCGs, one for Bums and the other for Skin and Soft Tissue Injury Except for 
Bums. Similarly, APG 633, Fracture Dislocation and Sprain was split into two 
based on anatomic site. This anatomic distinction is important as one PCG is 
more likely to incur packaged plain film ancillaries as compared to the other. 



PCG 481-494 Neonates and Pregnancy Related PCGs 

Other than code updates no changes occurred in these two MDCs 



104 



Final Report 



Summary of Difference Between Version 2.0 APGs and PCGs 



PCG 501-504 Infectious Disease PCGs 

Numerous code changes resulted in the creation of one new PCG and 
considerable movement of codes from one infectious disease PCG to another. 
Thus, Level I and Level II Infectious Disease PCGs were created with much 
more precision attached to complexity of the underlying infectious disease 
illness. In addition, the sexually transmitted APGs which were present in 
version 1 of the APGs were reconstituted for PCGs. This was done to 
recognize the frequency with which these conditions occur in the younger 
population in conjunction with the fact that the resource consumed for a 
sexually transmitted disease for females is typically significandy than that for 
males. 



PCGs 511-516 Neurologic PCGs 

Except for code updates and small movements of codes from Level I to Level 
n Diseases of the Nervous System (and vice versa) no changes occurred in 
this MDC. 



PCGs 531-534 Ophthalmologic PCGs 

Except for code updates and small movement of codes from other relatively 
simple PCGs to PCG 534 (or vice versa) no changes occurred in this MDC. 



PCGs 540-545 Ear, Nose, and Throat PCGs 

Except for code updates and small movement of codes from PCG 544 to PCG 
545 (or vice versa) no changes occurred in this MDC. 



PCGs 560-564 Respiratory PCGs 

A new PCG was created within this MDC. The emphysema, chronic 
bronchitis and asthma APG was split based on the patient's age. This was 
done to reflect the fact that resource consumption can be significantly higher 
in the adult population for the treatment of these diseases. In addition, it is 
important to profile these two PCGs differently due to the frequency with 
which this particular set of diagnoses occurs in the pediatric population. 



PCGs 569-576 Cardiovascular PCGs 

An important aspect of PCG development occurred in this MDC. 
Hypertension, the most frequently occurring encounter for physician offices 
was split into two: one pertaining to benign and unspecified hypertension 
(569) and a second pertaining to hypertension with complications (570). 
While, the hypertension with complication codes may not be often coded at 
the present time, this situation is likely to change and more accurate coding is 



The Development of a Physician Prospective Payment System for Ambulatory Care 1 05 



APPENDIX C 



likely to occur if distinctions are made within a classification system. Other 
than this important change, only code updates and minor code movement 
occurred within this MDC. 



PCGs 590—596 Gastrointestinal Disease PCGs 

The principal change which occurred pertaining to this MDC occurred with 
the creation of pediatric vs. adult distinctions for non-infectious 
gastroenteritis. This was done for two reasons: the frequency with which non- 
infectious gastroenteritis occurs in the pediatric population together with the 
differences in types of resources used in the treatment of this disease in these 
two different age groups. Other than this important change, only code updates 
and minor code movement occurred within this MDC. 



PCGs 621-628 [\/lusculosl<eletal System PCGs 

Except for code updates and small movements of codes from Level I to Level 
II Diseases of the Musculoskeletal System (and vice versa) no changes 
occurred in this MDC. 



PCGs 631-636 Sl<in and Breast Diseases 

The principal change which occurred pertaining to this MDC occurred with 
the creation of level I and level II Skin Diseases. This was done for two 
reasons: the frequency with which minor skin diseases occur in the general 
population together with the differences in types of resources used and time 
spent by the physician in the treatment of different types of skin diagnoses. 
Consequently, pemphigus, a complex skin disease, is separated from eczema 
a minor and extremely common skin disease. It is important to recognize that 
pemphigus, for example, will more likely be seen by a specialist while 
patients with eczema will be seen by general physicians and specialists alike. 
Other than this important change, only code updates and minor code 
movement occurred within this MDC. 



PCGs 650-654 Endocrine System PCGs 

An important aspect of PCG development occurred in this MDC. That is, 
diabetes, the second most frequently occurring disease specific encounter for 
physician offices was split into two: one pertaining to uncomplicated diabetes 
(650) and a second pertaining to diabetes with complications (651). Diabetes 
with complication codes are often coded at the present time, as these patients 
are often seen by different specialists and in different clinics. Other than this 
important change, only code updates and minor code movement occurred 
within this MDC. 



106 



Final Report 



Summary of Difference Between Version 2.0 APGs and PCGs 



• 



• 



PCGs 661-665 Genitourinary System PCGs 

Level 1 Urinary Diseases was split into two based on gender for several 
reasons: frequency of the diagnosis in females and importance of packaged 
ancillaries (the type of tests ordered are frequently different) particularly those 
that are likely to be packaged. Other than this important change, only code 
updates and minor code movement occurred within this MDC. 



PCGs 691-694 Immunologic and Hematologic System PCGs 

Only code updates and minor code movement occurred within this MDC. 

PCGs 701-705 Well Care and Administrative PCGs ; PCG 
721, Unknown Cause of Mortality; PCGs 989-999 Error PCGs 

Only code updates and minor code movement occurred within this MDC. 

PCGs 750-767, Dental PCGs 

An entire new set of PCGs were created to reflect the importance of Dental 
Care, particularly in Medicaid Programs. These were created using three axes 
of classification: 

• Type of dental service (Endodontics vs. Periodontics) 

• Complexity of Service (Level 1 vs. Level II prosthodontics) 

• Use of Ancillaries (Dental Plain Film or Dental Anesthesia). 

A total of 18 Dental PCGs were created. Sixteen were significant procedures 
and two, 766 (Dental Plain Film) and 767 (Dental Anesthesia) were 
professional ancillaries. 

PCGS 989 - 999, Error PCGs 

With the exception of PCG 989 and the movement of codes, the error PCGs 
were identical to the APG equivalents. PCG 989 Non-Covered Services 
Including Durable Medical Equipment. This PCG was expanded to include all 
otherwise unused HCPCS codes for durable medical equipment. 



The Development of a Physician Prospective Payment System for Ambulatory Care 1 07 



APPENDIX C 



"■"^ Final Report 



APPENDIX D 



ListofPCGs 



PCGs are categorized into clinically similar groups called Physician Care 
Categories (PCC). PCGs are classified as significant procedures (S), medical 
visits (M), professional ancillaries (P), ancillaries (A), incidentals (I) and error 
(E). 



The Development of a Physician Prospective Payment System for Ambulatory Care 109 



APPENDIX D 



SIGNIFICANT PROCEDURE AND THERAPY PCGs 

PCC 1 Integumentary System 

1 S PHOTOCHEMOTHERAPY 

2 S LEVEL I PERCUTANEOUS NEEDLE BIOPSY ASPIRATION, AND 

CANNULATION 

3 S LEVEL II PERCUTANEOUS NEEDLE BIOPSY ASPIRATION, AND 

CANNULATION 

4 S LEVEL I INCISION AND DRAINAGE 

5 S LEVEL II INCISION AND DRAINAGE 

6 S SIMPLE NAIL AND PODIATRIC PROCEDURES 

7 S LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION 

8 S LEVEL II DEBRIDEMENT AND DESTRUCTION 

9 S LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 

10 S LEVEL I SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 

11 S LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, 

AND NON-FIRST STAGE MOHS 

12 S LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT 

TISSUE 

13 S FIRST STAGE MOHS PROCEDURE 

14 S LEVEL I SKIN REPAIR 

15 S LEVEL II SKIN REPAIR 

16 S LEVEL III SKIN REPAIR 

17 S LEVEL IV SKIN REPAIR 

25 S BREAST RECONSTRUCTION AND MASTECTOMY 

26 S LEVEL I BREAST PROCEDURES 

27 S LEVEL 11 BREAST PROCEDURES 

PCC 2 Musculoskeletal System 

30 S LEVEL I MUSCULOSKELETAL PROCEDURES EXCLUDING HAND 

AND FOOT 

31 S LEVEL II MUSCULOSKELETAL PROCEDURES EXCLUDING HAND 

AND FOOT. 

32 S LEVEL III MUSCULOSKELETAL PROCEDURES EXCLUDING HAND 

AND FOOT 

33 S LEVEL I HAND AND FOOT PROCEDURE 

34 S LEVEL II HAND AND FOOT PROCEDURE 

35 S LEVEL III HAND AND FOOT PROCEDURE 

36 S ARTHROSCOPY 

37 S APPLICATION OF CASTS 

38 P SPLINT STRAPPING AND CAST REMOVAL 

39 P UNNA BOOT APPLICATION 

40 S CLOSED TREATMENT OF FRACTURES AND DISLOCATIONS OF 

HAND, FOOT, AND TRUNK 



110 



Final Report 



: '•;^'«V>. 



List of PCGs 



43 


S 


44 


S 


45 


S 


46 


S 


47 


S 


48 


S 



41 S CLOSED TREATMENT OF FRACTURES WITH MANIPULATION 

EXCEPT HAND, FOOT AND TRUNK 

42 S CLOSED TREATMENT OF DISLOCATIONS AND FRACTURES 

WITHOUT MANIPULATION EXCEPT HAND, FOOT, AND TRUNK 

OPEN OR PERCUTANEOUS TREATMENT OF FRACTURES 

BUNION PROCEDURES 

ARTHROPLASTY WITHOUT PROSTHESIS 

ARTHOPLASTY WITH PROSTHESIS 

HAND AND FOOT TENOTOMY 

ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 

PCC 3 Respiratory System 

55 P LEVEL I PULMONARY FUNCTION TESTS 

56 P LEVEL II PULMONARY FUNCTION TESTS 

57 S LEVEL III PULMONARY FUNCTION, STRESS, AND CHALLENGE 

TESTS 

58 S NEEDLE AND CATHETER BIOPSY ASPIRATION, LAVAGE AND 

INTUBATION 

59 S LEVEL I ENDOSCOPY OF THE UPPER AIRWAY AND MINOR 

LARYNGOSCOPY WITH BIOPSY 

LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 

LEVEL III ENDOSCOPY OF THE UPPER AIRWAY 

BRONCHOSCOPY 

RESPIRATORY THERAPY 

PCC 4 Cardiovascular System 

SIMPLE ECG 

CONTINUOUS AND COMPLEX ECG AND BLOOD PRESSURE 

MONITORING 

NON-INVASIVE VASCULAR STUDIES 

EXERCISE TOLERANCE TESTS 

ECHOCARDIOGRAPHY 

CARDIAC ELECTROPHYSIOLOGIC TESTS AND PROCEDURES 

DIAGNOSTIC CARDIAC CATHETERIZATION 

TRANSCATHETER PROCEDURES 

INJECTIONS FOR CARDIAC CATHETERIZATION 

NON-CARDIAC ARTERIAL ANGIOPLASTIES AND 

TRANSCATHETER PROCEDURES 

80 S NON-CARDIAC VENOUS ANGIOPLASTIES AND TRANSCATHETER 

INFUSIONS 

81 S PACEMAKER INSERTION AND DEFIBRILLATOR REPLACEMENT 

82 S VASCULAR DEVICE INSERTIONS 

83 S REMOVAL AND REVISION OF VASCULAR DEVICES AND 

PACEMAKERS 



The Development of a Physician Prospective Payment System for Ambulatory Care 1 1 1 



60 


S 


61 


S 


62 


S 


63 


S 



70 


P 


71 


P 


72 


P 


73 


S 


74 


P 


75 


S 


76 


S 


77 


S 


78 


S 


79 


S 



APPENDIX D 



84 S VASCULAR LIGATION 

85 S SIMPLE VARICOSE VEIN PROCEDURES 

86 S VASCULAR REPAIR AND FISTULA CONSTRUCTION 

87 S RESUSCITATION AND CARDIOVERSION 

88 S CARDIAC REHABILITATION 

89 S CENTRAL VENOUS CATHETER PLACEMENT 

PCC 5 Hematologic, Lymphatic and Endocrine 

90 P LEVEL I VENIPUNCTURE AND BLOOD COLLECTION 

91 P LEVEL II VENIPUNCTURE, SIMPLE VENOUS CATHETER 

PLACEMENT, AND ARTERIAL PUNCTURES 

92 S LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 

93 S LEVEL II ARTERIAL CATHETER PLACEMENT 

94 P INFUSION THERAPY EXCEPT CHEMOTHERAPY 

95 S CHEMOTHERAPY BY EXTENDED OR COMPLEX INFUSION 

96 S CHEMOTHERAPY EXCEPT BY EXTENDED INFUSION 

97 P SUBCUTANEOUS OR INTRAMUSCULAR CHEMOTHERAPY 

98 S BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT 

99 P THERAPEUTIC PHLEBOTOMY 

100 S BLOOD AND BLOOD PRODUCT EXCHANGE 

101 S TRANSFUSIONS 

105 S SIMPLE LYMPH NODE PROCEDURES 

106 S DEEP LYMPH STRUCTURE, THYROID, AND NECK PROCEDURES 

PCC 6 Digestive System 

ALIMENTARY TESTS 

SIMPLE UPPER Gl ENDOSCOPY 

THERAPEUTIC UPPER Gl ENDOSCOPY OR INTUBATION 

ESOPHAGEAL DILATION WITHOUT ENDOSCOPY 

LEVEL I COLONOSCOPY 

LEVEL II COLONOSCOPY 

PROCTOSIGMOIDOSCOPY WITH EXCISION OR BIOPSY 

SIMPLE ANOSCOPY 

ANOSCOPY WITH BIOPSY THERAPUTIC ANOSCOPY AND 

DIAGNOSTIC PROCTOSIGMOIDOSCOPY 

PERCUTANEOUS AND TRANSORAL BILLARY PROCEDURES 

HERNIA REPAIR EXCEPT UMBILICAL 

UMBILICAL HERNIAS, INTRAPERITONEAL, AND OTHER Gl 

PROCEDURES 

LEVEL I ANAL AND RECTAL PROCEDURES 

LEVEL II ANAL AND RECTAL PROCEDURES 

LEVEL I LAPAROSCOPIC PROCEDURES 

LEVEL II LAPAROSCOPIC PROCEDURES 



115 


S 


116 


S 


117 


S 


118 


S 


119 


S 


120 


S 


121 


S 


122 


P 


123 


S 


124 


S 


125 


S 


126 


S 


127 


S 


128 


S 


129 


S 


130 


S 



112 



Final Report 



•t"sfr;>,»„. 



List of PCGs 



PCC 7 Urinary System 

131 S RENAL EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY 

URINARY STUDIES AND PROCEDURES 
URINARY CATHETERIZATION AND DILATATION 
LEVEL I GENITOURINARY PROCEDURES 
LEVEL II GENITOURINARY PROCEDURES 
LEVEL III GENITOURINARY PROCEDURES 
UROFLOWMETRY 
HEMODIALYSIS 
PERITONEAL DIALYSIS 



132 


S 


133 


S 


134 


S 


135 


S 


136 


S 


137 


P 


145 


S 


146 


S 



PCC 8 Male Genital System 



150 


S 


151 


S 


152 


S 


153 


S 


154 


S 


155 


S 



TESTIS AND EPIDIDYMIS PROCEDURES 
INSERTION OF PENILE AND URINARY PROSTHESIS 
LEVEL I PENILE PROCEDURES AND CIRCUMCISION 
LEVEL II PENILE PROCEDURES 
VASECTOMY AND VAS DEFERENS PROCEDURES 
PROSTATE NEEDLE AND PUNCH BIOPSY 



PCC 9 Female Genital System 



160 


S 


161 


S 


162 


S 


163 


S 


164 


S 


165 


S 


166 


S 


167 


S 


168 


S 


169 


s 


170 


s 


171 


P 


172 


p 



INSERTION OF SUBCUTANEOUS CONTRACEPTIVE 

ARTIFICIAL FERTILIZATION 

PROCEDURES FOR PREGNANCY NEONATAL CARE, AND FETAL 

TESTING 

TREATMENT OF SPONTANEOUS ABORTION 

THERAPEUTIC ABORTION 

VAGINAL DELIVERY 

LEVEL I GYNECOLOGICAL PROCEDURES 

LEVEL II GYNECOLOGICAL PROCEDURES 

LEVEL III GYNECOLOGICAL PROCEDURES 

DILATION AND CURETTAGE 

HYSTEROSCOPY 

OTHER FEMALE REPRODUCTIVE PROCEDURES 

OBTAINING PAP SMEAR 



PCC 10 Nervous System 



180 


S 


181 


P 


182 


S 


190 


S 


191 


S 



EXTENDED EEG STUDIES AND SLEEP STUDIES 
ELECTROENCEPHALOGRAM 
ELECTROCONVULSIVE THERAPY 
LEVEL I NERVE AND MUSCLE TESTS 
LEVEL 11 NERVE AND MUSCLE TESTS 



The Development of a Physician Prospective Payment System for Ambulatory Care 113 



APPENDIX D 



192 S SPINAL CORD NEUROSTIMULATOR AND OTHER SPINAL CORD 

PROCEDURES 

INSERTION OF NEUROSTIMULATOR AND OTHER DEVICES 
NEUROSTIMULATOR ELECTRODE IMPLANTATION EXCEPT 
SPINAL 

REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 
MAJOR NERVE REPAIRS AND GRAFTS 
NERVE REPAIR AND DESTRUCTION 

SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 
SPINAL TAP 

SPINAL INJECTIONS FOR MYELOGRAPHY AND DISCOGRAPHGY 
INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 



193 


S 


194 


S 


195 


S 


196 


S 


197 


S 


198 


S 


199 


P 


200 


S 


201 


S 



PCC 11 Eye and Ocular Adnexa 



LEVEL I EYE TESTS AND PROCEDURES 

LEVEL II EYE TESTS AND PROCEDURES 

OPHTHALMOLGICAL EXAMINATIONS 

MINOR EYE EXAMINATIONS 

FITTING OF CONTACT LENSES AND LOW VISION AIDS 

FITTING OF SPECTACLE PROSTHESES 

LASER EYE PROCEDURES EXCEPT RETINAL 

LASER RETINAL PROCEDURES 

CATARACT PROCEDURES 

LEVEL I ANTERIOR SEGMENT EYE PROCEDURES 

LEVEL II ANTERIOR SEGMENT EYE PROCEDURES 

LEVEL III ANTERIOR SEGMENT EYE PROCEDURES 

CORNEAL TRANSPLANT 

LEVEL I VITRECTOMY AND POSTERIOR EYE PROCEDURE 

LEVEL II VITRECTOMY AND POSTERIOR EYE PROCEDURES 

EXTRAOCULAR MUSCLE PROCEDURES 

LEVEL I REPAIR AND PLASTIC PROCEDURES OF EYE 

LEVEL II REPAIR AND PLASTIC PROCEDURES OF EYE 

LEVEL III REPAIR AND PLASTIC PROCEDURES OF EYE 



PCC 12 Facial, Ear, Nose, Mouth and Throat 

COCHLEAR DEVICE IMPLANTATION 
OTORHINOLARYNGOLOGIC FUNCTION TESTS 
NASAL CAUTERIZATION AND PACKING 
LEVEL I FACIAL AND ENT PROCEDURES 
LEVEL II FACIAL AND ENT PROCEDURES 
LEVEL III FACIAL AND ENT PROCEDURES 
LEVEL IV FACIAL AND ENT PROCEDURES 
237 S TONSIL AND ADENOID PROCEDURES 



205 


S 


206 


S 


207 


S 


208 


S 


209 


S 


210 


P 


211 


S 


212 


S 


213 


S 


214 


S 


215 


S 


216 


S 


217 


S 


218 


S 


219 


S 


220 


S 


221 


S 


222 


S 


223 


s 



230 


s 


231 


S 


232 


S 


233 


S 


234 


S 


235 


S 


236 


S 



114 



Final Report 



>»t.&yr**» 



List of PCGs 



246 


S 


247 


S 


248 


S 


249 


S 


250 


S 


251 


S 


252 


S 


253 


S 


254 


S 


255 


S 



238 P COMPLEX AUDIOMETRY 

239 P REMOVAL OF IMPACTED CERUMEN AND FOREIGN BODIES 

240 P AUDIOMETRY 

PCC 13 Therapeutic and Other Significant Radiological Procedures 

245 S THERAPEUTIC RADIATION TREATMENT PLANNING 

LEVEL I THERAPEUTIC RADIATION TREATMENT PREPARATION 

LEVEL II THERAPEUTIC RADIATION TREATMENT PREPARATION 

BRACHYTHERAPY AND COMPLEX RADIOELEMENT 

APPLICATIONS 

RADIATION THERAPY MANAGEMENT 

RADIATION THERAPY 

HYPERTHERMIC THERAPIES 

HYPERBARIC THERAPIES 

LEVEL I THERAPEUTIC NUCLEAR MEDICINE 

LEVEL II THERAPEUTIC NUCLEAR MEDICINE 

RADIOPHARMACEUTICAL THERAPY OTHER THAN THYROID OR 

HEMATOLOGICAL 

256 S THERAPEUTIC RADIOLOGIC UROGRAPHIC PROCEDURES 

PCC 14 Radiology 

260 S FLUOROSCOPY 

261 S MYELOGRAPHY 

262 S DIAGNOSTIC UROGRAPHY 

263 S LEVEL I NON-IMAGING NUCLEAR MEDICINE 

264 S LEVEL II NON-IMAGING NUCLEAR MEDICINE 

265 S LEVEL I PLANAR 

266 S LEVEL II PLANAR 

267 S LEVEL I DIAGNOSTIC NUCLEAR MEDICINE 

268 S LEVEL II DIAGNOSTIC NUCLEAR MEDICINE 

269 S LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 

270 S DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 

271 S MAGNETIC RESONANCE ANGIOGRAPHY 

272 S ARTHOGRAPHY 

273 P OBSTETRICAL ULTRASOUND 

274 P VASCULAR ULTRASOUND 

275 S DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND 

VASCULAR 

276 S GUIDANCE UNDER ULTRASOUND 

277 S MAGNETIC RESONANCE IMAGING 

278 S COMPUTERIZED AXIAL TOMOGRAPHY 

279 S MAMMOGRAPHY 

280 S DIGESTIVE RADIOLOGY 



The Development of a Physician Prospective Payment System for Ambulatory Care 115 



APPENDIX D 



281 P PLAIN FILM 

282 S PET SCANS 

283 S MISCELLANEOUS RADIOLOGICAL PROCEDURES 

PCC 15 Mental Illness and Substance Abuse Therapies 

FULL DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE 

FULL DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 

HALF DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE 

HALF DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 

FAMILY PSYCHOTHERAPY 

GROUP PSYCHOTHERAPY 

SENILITY AND MENTAL RETARDATION THERAPY 

EXTENDED INDIVIDUAL MENTAL HEALTH AND SUBSTANCE 

ABUSE VISIT FOR A PERSON UNDER 18 

EXTENDED INDIVIDUAL MENTAL HEALTH AND SUBSTANCE 

ABUSE VISIT FOR A PERSON 18 AND OLDER 

BRIEF INDIVIDUAL VISIT FOR SUBSTANCE ABUSE FOR A 

PERSON UNDER EIGHTEEN 

BRIEF INDIVIDUAL VISIT FOR SUBSTANCE ABUSE FOR A 

PERSON EIGHTEEN AND OLDER 

BRIEF INDIVIDUAL VISIT FOR THOUGHT AND PERSONALITY 

DISORDERS FOR A PERSON UNDER EIGHTEEN 

BRIEF INDIVIDUAL VISIT FOR THOUGHT AND PERSONALITY 

DISORDERS FOR A PERSON EIGHTEEN AND OLDER 

BRIEF INDIVIDUAL VISIT FOR MENTAL HEALTH SYMPTONS AND / 

OR AFFECTIVE MENTAL DISORDERS FOR A PERSON UNDER 18 

BRIEF INDIVIDUAL VISIT FOR MENTAL HEALTH SYMPTONS AND / 

OR AFFECTIVE MENTAL DISORDERS FOR A PERSON 18 AND 

OLDER 

TREATMENT FOR ABUSE, ASSAULT OR RAPE FOR A PERSON 
UNDER 18 

TREATMENT FOR ABUSE, ASSAULT, OR RAPE FOR A PERSON 18 
AND OLDER 

NEUROPSYCHOLOGICAL TESTING 
ACTIVITY THERAPY 

PCC 16 Physical Medicine and Rehabilitation 

315 S BIOFEEDBACK AND OTHER TRAINING 

316 S OCCUPATIONAL THERAPY 

317 S PHYSICAL THERAPY 

318 S SPEECH THERAPY 

319 S MANIPULATION THERAPY 



290 


S 


291 


S 


292 


S 


293 


S 


294 


S 


295 


S 


296 


S 


297 


S 


298 


S 


299 


S 


300 


S 


301 


S 


302 


S 


303 


S 


304 


S 


305 


S 


306 


S 


307 


S 


308 


S 



116 



Final Report 



*->fm 



List of PCGs 



325 


P 


326 


S 


327 


P 


328 


S 


329 


S 


330 


P 


331 


P 


332 


P 



PCC 17 Injections and Tube Changes 

SIMPLE TUBE CHANGES AND INTRODUCTIONS 
SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 
INTRAMUSCULAR INJECTIONS 
ALLERGY TESTS 
ALLERGY INJECTIONS 
LEVEL I IMMUNIZATION 
LEVEL II IMMUNIZATION 
LEVEL III IMMUNIZATION 

PCC 18 Anesthesia 

335 S LEVEL i ANESTHESIA 

336 S LEVEL II ANESTHESIA 

337 S LEVEL III ANESTHESIA 

PCC 1 9 Other Physician Services 

340 P ELECTRONIC ANALYSIS OF PACEMAKERS AND OTHER DEVICES 

341 S PHYSICAN SUPERVISION OF ESRD 

342 S PHYSICIAN PROVIDED HOME HEALTH CARE 

343 S PHYSICIAN SUPERVISION OF HOME HEALTH CARE 

344 S MEDICAL CONFERENCES, PHONE CALLS, REPORTS AND 

PATIENT TESTS 

PCC 20 Laboratory and Pathology 

350 A LEVEL 1 PATHOLOGY 

351 A LEVEL I! PATHOLOGY 

352 A LEVEL III PATHOLOGY 

353 A PAP SMEARS 

354 A LABORATORY PROCEDURES FOR ARTIFICAL FERTILIZATION 

355 A BLOOD AND TISSUE TYPING 

356 A LEVEL I IMMUNOLOGY TESTS 

357 A LEVEL II IMMUNOLOGY TESTS 

358 A LEVEL I MICROBIOLOGY TESTS 

359 A LEVEL II MICROBIOLOGY TESTS 

360 A LEVEL I ENDOCRINOLOGY TESTS 

361 A LEVEL II ENDOCRINOLOGY TESTS 

362 A LEVEL I CHEMISTRY TESTS 

363 A LEVEL II CHEMISTRY TESTS 

364 A BASIC CHEMISTRY TESTS 

365 A MULTICHANNEL CHEMISTRY TESTS 

366 A ORGAN OR DISEASE ORIENTED PANELS 

367 A TOXICOLOGY TESTS 

368 A THERAPEUTIC DRUG MONITORING 

The Development of a Physician Prospective Payment System for Ambulatory Care 117 



APPENDIX D 



369 A LEVEL I CLOTTING TESTS 

370 A LEVEL II CLOTTING TESTS 

371 A LEVEL I HEMATOLOGY TESTS 

372 A LEVEL II HEMATOLOGY TESTS 

373 A URINALYSIS 

374 A BLOOD AND URINE DIPSTICK TESTS 

375 A STREP TEST 

376 A HEMATOCRIT AND HEMOGLOBIN 

377 A GLUCOSE 

PCC 21 Chemotherapy Agents and Other Pharmaceuticals 

391 A CLASS ONE CHEMOTHERAPY DRUGS 

392 A CLASS TWO CHEMOTHERAPY DRUGS 

393 A CLASS THREE CHEMOTHERAPY DRUGS 

394 A CLASS FOUR CHEMOTHERAPY DRUGS 

395 A CLASS FIVE CHEMOTHERAPY DRUGS 

396 A PHARMACEUTICALS 

PCC 22 Supplies and Agents 

400 A BLOOD PRODUCTS 

401 A ESRD SUPPLIES 

402 I IMAGING AGENTS 

403 A DISPOSABLE SUPPLIES 

PCC 23 Incidental Services 

421 I INCIDENTAL TO MEDICAL, SIGNIFICANT PROCEDURE OR 

THERAPY VISIT 

422 I MEDICAL VISIT INDICATOR 

423 I PSYCHIATRIC VISIT INDICATOR 

424 I MEDICAL VISIT INDICATOR -SEX SPECIFIC 

425 I MEDICAL VISIT INDICATOR - AGE SPECIFIC 

MEDICAL PCCS 



PCC 24 Malignancy 

431 M HEMATOLOGICAL MALIGNANCY 

432 M PROSTATIC MALIGNANCY 

433 M LUNG MALIGNANCY 

434 M BREAST MALIGNANCY 

435 M Gl MALIGNANCY 

436 M SKIN MALIGNANCY 

437 M OTHER MALIGNANCY 



118 



Final Report 



List of PCGs 



• 



• 



PCC 26 Trauma 


460 


M 1 


461 


M 1 


462 


M I 


463 


M 1 



PCC 25 Poisoning 

451 M POISONING 



HEAD AND SPINE INJURY 

MINOR SKIN AND SOFT TISSUE INJURIES EXCEPT BURNS 

SKIN AND SOFT TISSUE INJURIES EXCEPT BURNS 

FRACTURE, DISLOCATION AND SPRAIN OF FINGERS, TOES, AND 

TRUNK 

464 M FRACTURE, DISLOCATION AND SPRAIN EXCEPT FINGERS, 

TOES, AND TRUNK 

465 M BURNS 

466 M OTHER INJURIES 

PCC 27 Neonate 

481 M NEONATES AND CONGENITAL ANOMALIES 

PCC 28 Pregnancy 

491 M ROUTINE PRENATAL CARE 

492 M MATERNAL ANTEPARTUM COMPLICATION 

493 M ROUTINE POSTPARTUM CARE 

494 M MATERNAL POSTPARTUM COMPLICATION 

PCC 29 Infectious Diseases 

LEVEL I INFECTIOUS DISEASES 

LEVEL II INFECTIOUS DISEASE 

INFECTIOUS DISEASES OF GENITAL ORGANS - FEMALES 

INFECTIOUS DISEASES OF GENITAL ORGANS - MALES 

PCC 30 Nervous System Diseases 

TIA, CVA AND OTHER CEREBROVASCULAR EVENTS 

HEADACHE 

EPILEPSY 

NON TRAUMATIC LOSS OF CONSCIOUSNESS AND 

CONVULSIONS 

515 M LEVEL i DISEASES OF THE NERVOUS SYSTEM 

51 6 M LEVEL II DISEASES OF THE NERVOUS SYSTEM 

PCC 31 Eye Diseases 

531 M CATARACTS 



The Development of a Physician Prospective Payment System for Ambulatory Care 1 19 



501 


M 


502 


M 


503 


M 


504 


M 



511 


M 


512 


M 


513 


M 


514 


M 



APPENDIX D 



532 M REFRACTION DISORDER 

533 M CONJUNCTIVITIS AND OTHER SIMPLE EXTERNAL EYE 

INFLAMMATION 

534 M EYE DISEASES EXCEPT CATARACT, RE FRACTION DISORDER & 

CONJUNCTIVITIS 

FCC 32 Ear, Nose, Mouth and Throat Diseases 

540 M INFLUENZA, URI AND ENT INFECTIONS - PEDIATRIC 

541 M DENTAL DISEASE 

542 M INFLUENZA, URI AND ENT INFECTIONS - NON-PEDIATRIC 

543 M HEARING LOSS 

544 M OTHER LEVEL I EAR, NOSE, THROAT AND MOUTH DISEASES 

545 M OTHER LEVEL II EAR, NOSE, THROAT AND MOUTH DISEASES 

PCC 33 Respiratory System Diseases 

560 M EMPHYSEMA, CHRONIC BRONCHITIS, AND ASTHMA - PEDIATRIC 

561 M EMPHYSEMA, CHRONIC BRONCHITIS, AND ASTHMA -NON- 

PEDIATRIC 

562 M PNEUMONIA 

563 M LEVEL I RESPIRATORY DIS EXC EMPHYSEMA.CHR BRONCHITIS 

& ASTHMA 

564 M LEVEL II RESPIRATORY DIS EXC EMPHYSEMA.CHR BRONCHITIS 

& ASTHMA 

PCC 34 Cardiovascular System Diseases 

569 M BENIGN AND UNSPECIFIED HYPERTENSION 

570 M HYPERTENSION WITH COMPLICATIONS 

571 M CONGESTIVE HEART FAILURE AND ISCHEMIC HEART DISEASE 

573 M CHEST PAIN W CARDIAC ENZYMES TO RULE OUT MYOCARDIAL 

INFARCT 

574 M CHEST PAIN WO CARDIAC ENZYMES TO RULE OUT 

MYOCARDIAL INFARCT 

575 M LEVEL I CARDIOVASCULAR DIS EXC CHRISCHEMIC HEART DIS & 

HYPERTN 

576 M LEVEL II CARDIOVASCULAR DIS EXC CHRISCHEMIC HEART DIS 

& HYPERTN 

PCC 35 Digestive System Diseases 

590 M NONINFECTIOUS GASTROENTERITIS - PEDIATRIC 

591 M NONINFECTIOUS GASTROENTERITIS - NON-PEDIATRIC 

592 M ULCERS, GASTRITIS AND ESOPHAGITIS 

593 M HEPATOBILIARY DISEASE 



120 



Final Report 



■^m 



List of PCGs 



594 M HERNIA 

595 M HEMORRHOIDS AND OTHER ANAL-RECTAL DISEASES 

596 M OTHER LEVEL I GASTROINTESTINAL DISEASES 

597 M OTHER LEVEL II GASTROINTESTINAL DISEASES 

PCC 36 Major Signs, symptoms and Findings 

61 1 M MAJOR SIGNS, SYMPTOMS AND FINDINGS 

PCC 37 Musculoskeletal Diseases 

621 M BACK DISORDERS 

622 M LEVEL I MUSCULOSKELETAL DISEASES EXCEPT BACK 

DISORDERS 
628 M LEVEL II MUSCULOSKELETAL DISEASES EXCEPT BACK 

DISORDERS 

PCC 38 Sl<in and Breast Diseases 

631 M DISEASE OF NAILS 

632 M CHRONIC SKIN ULCER 

633 M CELLULITIS, IMPETIGO AND LYMPHANGITIS 

634 M BREAST DISEASES 

635 M LEVEL I SKIN DISEASES 

636 M LEVEL II SKIN DISEASES 

PCC 39 Endocrine, Nutritional and Metabolic Diseases 

LEVEL I DIABETES 

LEVEL II DIABETES 

LEVEL 1 ENDOCRINE, NUTRITIONAL & METABLIC DISEASE, INCL 

OBESITY AND EXC DIABETES 

LEVEL II ENDOCRINE.NUTRIT & METABOLIC DIS EXC DIABETES 

& OBESITY 

FLUID AND ELECTROLYTE DISORDERS 

PCC 40 Kidney and Urinary Tract Diseases 

URINARY TRACT INFECTION 

RENAL FAILURE 

LEVEL I URINARY DIS EXC URINARY TRACT INFECTN & RENAL 

FAILURE - FEMALES 

LEVEL I URINARY DIS EXC URINARY TRACT INFECTN & RENAL 

FAILURE - MALES 

LEVEL II URINARY DIS EXC URINARY TRACT INFECTN & RENAL 

FAILURE 



The Development of a Physician Prospective Payment System for Ambulatory Care 121 



650 


M 


651 


M 


652 


M 


653 


M 


654 


M 



661 


M 


662 


M 


663 


M 


664 


M 


665 


M 



APPENDIX D 



PCC 41 Male Genital System Diseases 

672 M MALE REPRODUCTIVE DISEASES EXCEPT BENIGN PROSTATIC 

HYPERTROPHY 

PCC 42 Female Genital System Diseases 

681 M GYNECOLOGIC DISEASES 

691 M HIV INFECTION 

PCC 43 Immunologic and Hematologic Diseases 

ANEMIA 

OTHER LEVEL I IMMUNOLOGIC AND HEMATOLOGIC DISEASE 

OTHER LEVEL II IMMUNOLOGIC AND HEMATOLOGIC DISEASE 

PCC 44 Well Care, Administrative 

701 M ADULT MEDICAL EXAMINATION 

702 M WELL CHILD CARE 

703 M CONTRACEPTION AND PROCREATIVE MANAGEMENT 

704 M AFTERCARE 

705 M NONSPECIFIC SIGNS & SYMPTOMS &OTH CONTACTS W HEALTH 

SVCS 

PCC 45 Unknown Cause of Mortality 

UNKNOWN CAUSE OF MORTALITY 
DENTAL EXAMINATION 



692 


M 


693 


M 


694 


M 



721 


M 


750 


S 


PCC 46 Dental 


751 


S 


752 


S 


753 


S 


754 


S 


755 


S 


756 


S 


757 


S 


758 


S 


759 


S 


760 


S 


761 


S 


762 


S 


763 


S 


764 


S 



PREVENTIVE DENTAL PROCEDURES 

DENTAL PROSTHESIS 

LEVEL I DENTAL RESTORATIONS 

LEVEL II DENTAL RESTORATIONS 

ENDODONTICS 

PERIODONTICS 

LEVEL I PROSTHODONTICS 

LEVEL II PROSTHODONTICS 

DENTAL MAXILLOFACIAL PROSTHETICS 

LEVEL I ORAL AND MAXILLOFACIAL SURGERY 

LEVEL 1! ORAL AND MAXILLOFACIAL SURGERY 

LEVEL I ORTHODONTICS 

LEVEL II ORTHODONTICS 

OTHER DENTAL VISITS 



''22 Final Report 



(i ".-, 



List of PCGs 



o 



765 P MINOR MISCELLANEOUS DENTAL PROCEDURES 

766 P DENTAL PLAIN FILM 

767 P DENTAL ANESTHESIA 

PCC 47 Error 

989 E NON-COVERED SERVICES INCLUDING DURABLE MEDICAL 

EQUIPMENT 

INVALID PROCEDURE CODE 
INPATIENT PROCEDURE 
AUTOPSY SERVICES 

NON COVERED CARE SETTINGS AND SERVICES 
INVALID RVDX CODE 
ECODE CANNOT BE USED AS RVDX 
UNACCEPTABLE RVDX, REQUIRES PROCEDURE 
UNGROUPABLE 



992 


E 


993 


E 


994 


E 


995 


E 


996 


E 


997 


E 


998 


E 


999 


E 



The Development of a Physician Prospective Payment System for Ambulatory Care 123 



APPENDIX D 



^^^ Final Report 



APPENDIX E 



Map of HCPCS Codes to PCGs 



The third column in Appendix E is the PCG service class which is defined as 
follows: 

Class Description Deflnition 

C Complete Service class is always complete 

M Modifier Dependent Service class assigned based on the presence of a modifier 

P Professional Service class is always professional 

T Technical Service class is always technical 



125 



APPENDIX E 


- 






Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


00528 


337 


C 


00866 


336 


C 


00100 


336 


C 


00530 


336 


C 


00868 


993 


C 


00102 


337 


C 


00532 


336 


C 


00870 


336 


C 


00103 


336 


c 


00534 


337 


C 


00872 


337 


C 


00104 


335 


c 


00540 


993 


C 


00873 


337 


C 


00120 


336 


c 


00542 


993 


c 


00880 


335 


C 


00124 


335 


c 


00544 


993 


C 


00882 


336 


C 


00126 


335 


c 


00546 


993 


C 


00884 


336 


C 


00140 


336 


c 


00548 


993 


C 


00900 


335 


C 


00142 


335 


c 


00560 


993 


C 


00902 


335 


C 


00144 


.- 337 


c 


00562 


993 


C 


00904 


337 


C 


00145 - 


337 


c 


00580 


993 


C 


00906 


336 


C 


00147 


336 


c 


00600 


337 


c 


00908 


337 


C 


00148 


335 


c 


00604 


993 


C 


00910 


335 


C 


00160 


336 


c 


00620 


337 


C 


00912 


336 


C 


00162 


337 


c 


00622 


993 


C 


00914 


336 


C 


00164 


335 


c 


00630 


337 


C 


00916 


336 


C 


00170 


336 


c 


00632 


337 


C 


00918 


336 


C 


00172 


336 


c 


00634 


337 


C 


00920 


335 


C 


00174 


336 


c 


00670 


993 


C 


00922 


336 


C 


00176 


337 


c 


00700 


335 


C 


00924 


336 


C 


00190 


336 


c 


00702 


336 


C 


00926 


336 


C 


00192 


335 


c 


00730 


336 


C 


00928 


337 


C 


00210 


993 


c 


00740 


335 


C 


00930 


336 


C 


00212 


993 


c 


00750 


336 


C 


00932 


336 


C 


00214 


993 


c 


00752 


336 


C 


00934 


993 


C 


00215 


993 


c 


00754 


336 


C 


00936 


337 


C 


00216 


993 


c 


00756 


337 


c 


00938 


336 


C 


00218 


993 


c 


00770 


993 


C 


00940 


335 


C 


00220 


993 


c 


00790 


337 


C 


00942 


336 


C 


00222 


336 


c 


00792 


335 


c 


00944 


337 


C 


00300 


336 


c 


00794 


993 


C 


00946 


335 


c 


00320 


336 


c 


00796 


993 


c 


00948 


335 


C 


00322 


337 


c 


00800 


335 


c 


00950 


336 


C 


00350 


337 


c 


00802 


336 


c 


00952 


335 


c 


00352 


336 


c 


00806 


336 


c 


00955 


336 


c 


00400 


335 


c 


00810 


336 


c 


01000 


336 


C 


00402 


337 


c 


00820 


336 


c 


OHIO 


336 


C 


00404 


336 


c 


00830 


336 


c 


01120 


337 


C 


00406 


335 


c 


00832 


336 


c 


01130 


335 


C 


00410 


335 


c 


00840 


337 


c 


01140 


993 


C 


00420 


336 


c 


00842 


335 


c 


01150 


993 


C 


00450 


336 


c 


00844 


337 


c 


01160 


336 


C 


00452 


335 


c 


00846 


337 


c 


01170 


336 


C 


00454 


335 


c 


00848 


337 


c 


01180 


335 


C 


00470 


336 


c 


00850 


337 


c 


01190 


335 


C 


00472 


993 


c 


00855 


336 


c 


01200 


335 


C 


00474 


993 


c 


00857 


337 


c 


01202 


337 


C 


00500 


993 


c 


00860 


336 


c 


01210 


337 


C 


00520 


336 


c 


00862 


337 


c 


01212 


337 


C 


00522 


336 


c 


00864 


993 


c 


01214 


337 


C 


00524 


336 


c 


00865 


993 


c 


01220 


335 


c 


126 














Final 


Report 



,T*'~il'-. 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


01230 


337 


C 


01654 


337 


C 


10060 


004 


C 


01232 


336 


C 


01656 


337 


C 


10061 


005 


C 


01234 


337 


C 


01670 


335 


C 


10080 


004 


C 


01240 


335 


C 


01680 


335 


C 


10081 


004 


C 


01250 


336 


C 


01682 


335 


C 


10120 


004 


C 


01260 


336 


C 


01700 


335 


C 


10121 


Oil 


C 


01270 


337 


C 


01710 


336 


C 


10140 


004 


C 


01272 


337 


C 


01712 


336 


C 


10160 


004 


C 


01274 


337 


C 


01714 


336 


C 


10180 


004 


C 


01300 


335 


C 


01716 


336 


C 


11000 


007 


C 


01320 


. 336 


C 


01730 


335 


C 


llOOI 


007 


C 


01340 - 


336 


C 


01732 


336 


C 


11040 


007 


C 


01360 


336 


C 


01740 


336 


C 


11041 


007 


C 


01380 


335 


c 


01742 


336 


C 


11042 


007 


C 


01382 


335 


c 


01744 


337 


c 


11043 


009 


c 


01390 


335 


c 


01756 


336 


c 


11044 


009 


c 


01392 


336 


c 


01758 


336 


c 


11050 


007 


c 


01400 


336 


c 


01760 


335 


c 


11051 


007 


c 


01402 


337 


c 


01770 


337 


c 


11052 


007 


c 


01404 


335 


c 


01772 


337 


c 


11100 


010 


c 


01420 


335 


c 


01780 


335 


c 


11101 


010 


c 


01430 


337 


c 


01782 


337 


c 


11200 


007 


c 


01432 


336 


c 


01784 


337 


c 


11201 


007 


c 


01440 


337 


c 


01800 


335 


c 


11300 


007 


c 


01442 


335 


c 


01810 


335 


c 


11301 


008 


c 


01444 


337 


c 


01820 


335 


c 


11302 


008 


c 


01460 


335 


c 


01830 


336 


c 


11303 


008 


c 


01462 


335 


c 


01832 


336 


c 


11305 


007 


c 


01464 


336 


c 


01840 


337 


c 


11306 


008 


c 


01470 


336 


c 


01842 


337 


c 


11307 


008 


c 


01472 


336 


c 


01844 


337 


c 


11308 


008 


c 


01474 


335 


c 


01850 


336 


c 


11310 


007 


c 


01480 


336 


c 


01852 


336 


c 


11311 


008 


c 


01482 


336 


c 


01860 


335 


c 


11312 


008 


c 


01484 


336 


c 


01900 


335 


c 


11313 


008 


c 


01486 


335 


c 


01902 


335 


c 


11400 


010 


c 


01490 


335 


c 


01904 


335 


c 


11401 


010 


c 


01500 


337 


c 


01906 


335 


c 


11402 


Oil 


c 


01502 


337 


c 


01908 


335 


c 


11403 


Oil 


c 


01520 


336 


c 


01910 


335 


c 


11404 


Oil 


c 


01522 


336 


c 


01912 


335 


c 


11406 


012 


c 


01600 


335 


c 


01914 


337 


c 


11420 


010 


c 


01610 


336 


c 


01916 


336 


c 


11421 


010 


c 


01620 


335 


c 


01918 


336 


c 


11422 


on 


c 


01622 


336 


c 


01920 


336 


c 


11423 


on 


c 


01630 


337 


c 


01921 


337 


c 


11424 


on 


c 


01632 


993 


c 


01922 


337 


c 


11426 


012 


c 


01634 


337 


c 


01990 


993 


c 


11440 


010 


c 


01636 


993 


c 


01995 


336 


c 


11441 


010 


c 


01638 


337 


c 


01996 


993 


c 


11442 


on 


c 


01650 


336 


c 


01999 


335 


c 


11443 


on 


c 


01652 


337 


c 


10040 


004 


c 


11444 


on 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



127 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


11446 


012 


C 


11970 


017 


C 


14020 


016 


C 


11450 


012 


C 


11971 


012 


C 


14021 


017 


C 


11451 


012 


c 


11975 


160 


C 


14040 


016 


C 


11462 


012 


c 


11976 


010 


C 


14041 


017 


C 


11463 


012 


c 


11977 


160 


C 


14060 


017 


C 


11470 


012 


c 


12001 


014 


C 


14061 


017 


C 


11471 


012 


c 


12002 


014 


C 


14300 


017 


C 


11600 


010 


c 


12004 


014 


C 


14350 


017 


C 


11601 


010 


c 


12005 


015 


C 


15000 


015 


C 


11602 


Oil 


c 


12006 


015 


C 


15050 


015 


C 


11603 


. Oil 


c 


12007 


015 


C 


15100 


017 


C 


11604 - 


Oil 


c 


12011 


014 


C 


15101 


014 


C 


11606 


012 


c 


12013 


014 


C 


15120 


017 


C 


11620 


010 


c 


12014 


014 


C 


15121 


014 


C 


11621 


010 


c 


12015 


015 


C 


15200 


017 


C 


11622 


Oil 


c 


12016 


015 


C 


15201 


014 


C 


11623 


Oil 


c 


12017 


015 


c 


15220 


017 


C 


11624 


012 


c 


12018 


016 


C 


15221 


015 


C 


11626 


012 


c 


12020 


014 


c 


15240 


017 


C 


11640 


010 


c 


12021 


014 


C 


15241 


014 


C 


11641 


Oil 


c 


12031 


014 


c 


15260 


017 


c 


11642 


Oil 


c 


12032 


014 


C 


15261 


014 


C 


11643 


Oil 


c 


12034 


014 


c 


15350 


015 


C 


11644 


012 


c 


12035 


015 


C 


15400 


015 


c 


11646 


012 


c 


12036 


015 


C 


15570 


016 


C 


11700 


006 


c 


12037 


015 


C 


15572 


016 


C 


11701 


006 


c 


12041 


014 


C 


15574 


016 


C 


11710 


006 


c 


12042 


014 


C 


15576 


015 


C 


11711 


006 


c 


12044 


014 


C 


15580 


016 


C 


11730 


007 


c 


12045 


015 


C 


15600 


015 


C 


11731 


007 


c 


12046 


015 


C 


15610 


015 


C 


11732 


007 


c 


12047 


015 


C 


15620 


015 


C 


11740 


006 


c 


12051 


014 


c 


15625 


015 


C 


11750 


Oil 


c 


12052 


014 


C 


15630 


015 


C 


11752 


012 


c 


12053 


014 


C 


15650 


015 


C 


11755 


010 


c 


12054 


015 


C 


15732 


017 


C 


11760 


014 


c 


12055 


015 


C 


15734 


017 


C 


11762 


015 


c 


12056 


016 


C 


15736 


017 


C 


11765 


007 


c 


12057 


016 


C 


15738 


017 


C 


11770 


Oil 


c 


13100 


015 


C 


15740 


017 


C 


11771 


012 


c 


13101 


015 


C 


15750 


017 


C 


11772 


012 


c 


13120 


015 


C 


15755 


017 


C 


11900 


007 


c 


13121 


015 


C 


15760 


017 


C 


11901 


007 


c 


13131 


015 


C 


15770 


017 


C 


11920 


014 


c 


13132 


015 


c 


15775 


015 


C 


11921 


014 


c 


13150 


015 


C 


15776 


015 


C 


11922 


014 


c 


13151 


015 


c 


15780 


009 


C 


11950 


014 


c 


13152 


016 


c 


15781 


009 


C 


11951 


014 


c 


13160 


016 


C 


15782 


016 


C 


11952 


014 


c 


13300 


015 


C 


15783 


008 


c 


11954 


014 


c 


14000 


016 


c 


15786 


008 


C 


11960 


017 


c 


14001 


016 


c 


15787 


007 


C 


128 














Final 


Report 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


15788 


008 


C 


15950 


016 


C 


17305 


Oil 


C 


15789 


008 


C 


15951 


016 


C 


17306 


Oil 


C 


15790 


008 


C 


15952 


017 


C 


17307 


oil 


C 


15791 


008 


C 


15953 


017 


C 


17310 


Oil 


C 


15792 


008 


C 


15956 


017 


C 


17340 


007 


C 


15793 


008 


C 


15958 


017 


C 


17360 


007 


C 


15810 


008 


C 


15999 


014 


C 


17380 


007 


C 


15811 


009 


C 


16000 


007 


C 


17999 


007 


C 


15819 


017 


C 


16010 


007 


C 


19000 


002 


C 


15820 


016 


C 


16015 


993 


C 


19001 


002 


c 


15821 . 


016 


C 


16020 


007 


C 


19020 


005 


C 


15822 - 


016 


C 


16025 


008 


c 


19030 


326 


C 


15823 


016 


C 


16030 


008 


C 


19100 


002 


c 


15824 


016 


C 


16035 


on 


c 


19101 


026 


C 


15825 


016 


C 


16040 


Oil 


C 


19110 


026 


C 


15826 


016 


C 


16041 


Oil 


C 


19112 


026 


C 


15828 


016 


C 


16042 


Oil 


C 


19120 


026 


C 


15829 


016 


C 


17000 


007 


c 


19125 


026 


C 


15831 


016 


C 


17001 


007 


C 


19126 


026 


c 


15832 


016 


C 


17002 


007 


c 


19140 


027 


c 


15833 


016 


c 


17010 


007 


c 


19160 


027 


C 


15834 


016 


c 


17100 


007 


C 


19162 


025 


C 


15835 


016 


c 


17101 


007 


c 


19180 


025 


C 


15836 


016 


c 


17102 


007 


C 


19182 


025 


C 


15837 


016 


c 


17104 


007 


C 


19200 


993 


C 


15838 


012 


c 


17105 


007 


C 


19220 


993 


C 


15839 


016 


c 


17106 


015 


C 


19240 


025 


C 


15840 


017 


c 


17107 


016 


c 


19260 


032 


C 


15841 


017 


c 


17108 


016 


C 


19271 


993 


C 


15842 


017 


c 


17110 


007 


C 


19272 


993 


C 


15845 


017 


c 


17200 


007 


C 


19290 


002 


C 


15850 


007 


c 


17201 


007 


c 


19291 


002 


C 


15851 


007 


c 


17250 


007 


C 


19316 


025 


C 


15852 


007 


c 


17260 


007 


C 


19318 


025 


C 


15860 


326 


c 


17261 


008 


C 


19324 


027 


C 


15876 


016 


c 


17262 


008 


C 


19325 


025 


C 


15877 


016 


c 


17263 


009 


C 


19328 


027 


C 


15878 


016 


c 


17264 


009 


C 


19330 


027 


C 


15879 


016 


c 


17266 


009 


c 


19340 


025 


C 


15920 


016 


c 


17270 


007 


c 


19342 


025 


C 


15922 


017 


c 


17271 


007 


C 


19350 


025 


C 


15931 


016 


c 


17272 


008 


C 


19355 


025 


C 


15933 


016 


c 


17273 


009 


c 


19357 


025 


C 


15934 


017 


c 


17274 


009 


c 


19361 


993 


c 


15935 


017 


c 


17276 


009 


C 


19362 


993 


c 


15936 


017 


c 


17280 


008 


c 


19364 


025 


c 


15937 


017 


c 


17281 


009 


c 


19366 


025 


C 


15940 


016 


c 


17282 


009 


c 


19367 


993 


C 


15941 


016 


c 


17283 


009 


c 


19368 


993 


c 


15944 


017 


c 


17284 


009 


c 


19369 


993 


c 


15945 


017 


c 


17286 


009 


c 


19370 


025 


c 


15946 


017 


c 


17304 


013 


c 


19371 


025 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



129 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


19380 


025 


C 


20828 


993 


C 


21083 


236 


C 


19396 


026 


C 


20832 


993 


C 


21084 


236 


C 


19499 


026 


C 


20834 


993 


C 


21085 


234 


c 


20000 


004 


C 


20838 


993 


C 


21086 


236 


c 


20005 


005 


C 


20840 


993 


C 


21087 


236 


C 


20100 


015 


C 


20900 


030 


C 


21088 


236 


C 


20101 


015 


C 


20902 


993 


C 


21089 


233 


C 


20102 


015 


C 


20910 


016 


C 


21100 


236 


C 


20103 


015 


C 


20912 


016 


C 


21110 


235 


C 


20200 


Oil 


C 


20920 


016 


C 


21116 


326 


C 


20205 


. Oil 


C 


20922 


016 


C 


21120 


235 


c 


20206 . 


002 


C 


20924 


031 


C 


21121 


235 


C 


20220 


003 


C 


20926 


015 


C 


21122 


235 


C 


20225 


003 


c 


20930 


993 


C 


21123 


235 


C 


20240 


030 


c 


20931 


993 


C 


21125 


235 


C 


20245 


030 


c 


20936 


993 


C 


21127 


235 


C 


20250 


031 


c 


20937 


993 


C 


21137 


235 


c 


20251 


031 


c 


20938 


993 


c 


21138 


236 


C 


20500 


233 


c 


20950 


058 


C 


21139 


236 


C 


20501 


326 


c 


20955 


032 


c 


21141 


993 


c 


20520 


002 


c 


20960 


032 


c 


21142 


993 


C 


20525 


030 


c 


20962 


032 


c 


21143 


993 


C 


20550 


048 


c 


20969 


032 


c 


21144 


993 


C 


20600 


048 


c 


20970 


032 


c 


21145 


993 


C 


20605 


048 


c 


20971 


032 


c 


21146 


993 


C 


20610 


048 


c 


20972 


035 


c 


21147 


993 


C 


20615 


002 


c 


20973 


035 


c 


21150 


993 


C 


20650 


040 


c 


20974 


317 


c 


21151 


993 


c 


20660 


037 


c 


20975 


030 


c 


21154 


993 


c 


20661 


993 


c 


20999 


030 


c 


21155 


993 


C 


20662 


037 


c 


21010 


235 


c 


21159 


993 


C 


20663 


037 


c 


21015 


235 


c 


21160 


993 


C 


20665 


038 


c 


21025 


235 


c 


21172 


993 


C 


20670 


002 


c 


21026 


235 


c 


21175 


993 


C 


20680 


033 


c 


21029 


235 


c 


21179 


993 


C 


20690 


030 


c 


21030 


235 


c 


21180 


993 


c 


20692 


031 


c 


21031 


234 


c 


21181 


993 


c 


20693 


030 


c 


21032 


234 


c 


21182 


993 


C 


20694 


030 


c 


21034 


236 


c 


21183 


993 


C 


20802 


993 


c 


21040 


234 


c 


21184 


993 


c 


20804 


993 


c 


21041 


235 


c 


21188 


993 


c 


20805 


993 


c 


21044 


235 


c 


21193 


993 


C 


20806 


993 


c 


21045 


236 


c 


21194 


993 


C 


20808 


993 


c 


21050 


235 


c 


21195 


993 


C 


20812 


993 


c 


21060 


235 


c 


21196 


993 


C 


20816 


993 


c 


21070 


235 


c 


21198 


235 


c 


20820 


993 


c 


21076 


989 


c 


21206 


236 


c 


20822 


035 


c 


21077 


989 


c 


21208 


236 


c 


20823 


035 


c 


21079 


236 


c 


21209 


235 


c 


20824 


993 


c 


21080 


236 


c 


21210 


236 


c 


20826 


993 


c 


21081 


236 


c 


21215 


236 


c 


20827 


993 


c 


21082 


236 


c 


21230 


236 


c 


130 














Final 


Report 



• 



• 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


21235 


235 


C 


21400 


233 


C 


21740 


993 


C 


21240 


236 


C 


21401 


234 


C 


21750 


993 


C 


21242 


236 


C 


21406 


235 


C 


21800 


040 


C 


21243 


236 


C 


21407 


236 


C 


21805 


043 


C 


21244 


236 


C 


21408 


993 


C 


21810 


993 


C 


21245 


236 


C 


21421 


235 


C 


21820 


040 


C 


21246 


236 


C 


21422 


993 


c 


21825 


043 


C 


21247 


993 


c 


21423 


993 


C 


21899 


233 


C 


21248 


236 


c 


21431 


993 


C 


21920 


010 


C 


21249 


236 


c 


21432 


993 


c 


21925 


012 


C 


21255 . 


993 


c 


21433 


993 


c 


21930 


012 


C 


21256 . 


993 


c 


. 21435 


993 


c 


21935 


993 


C 


21260 


236 


c 


21436 


993 


c 


22100 


993 


C 


21261 


236 


c 


21440 


234 


c 


22101 


993 


C 


21263 


236 


c 


21445 


235 


c 


22102 


993 


C 


21267 


993 


c 


21450 


234 


c 


22103 


993 


C 


21268 


993 


c 


21451 


235 


c 


22105 


993 


C 


21270 


236 


c 


21452 


234 


c 


22106 


993 


C 


21275 


236 


c 


21453 


235 


c 


22107 


993 


C 


21280 


235 


c 


21454 


235 


c 


22110 


993 


C 


21282 


235 


c 


21461 


236 


c 


22112 


993 


c 


21295 


234 


c 


21462 


236 


c 


22114 


993 


C 


21296 


236 


c 


21465 


236 


c 


22116 


993 


C 


21299 


233 


c 


21470 


236 


c 


22140 


993 


C 


21300 


233 


c 


21480 


233 


c 


22141 


993 


C 


21310 


233 


c 


21485 


234 


c 


22142 


993 


C 


21315 


233 


c 


21490 


236 


c 


22145 


993 


c 


21320 


233 


c 


21493 


993 


c 


22148 


993 


C 


21325 


234 


c 


21494 


993 


c 


22150 


993 


C 


21330 


235 


c 


21495 


993 


c 


22151 


993 


C 


21335 


235 


c 


21497 


234 


c 


22152 


993 


C 


21336 


043 


c 


21499 


233 


c 


22210 


993 


C 


21337 


233 


c 


21501 


005 


c 


22212 


993 


C 


21338 


235 


c 


21502 


031 


c 


22214 


993 


C 


21339 


235 


c 


21510 


031 


c 


?■>->! 6 


993 


C 


21340 


236 


c 


21550 


010 


c 


????,0 


993 


C 


21343 


236 


c 


21555 


012 


c 


2??72 


993 


C 


21344 


993 


c 


21556 


012 


c 


22224 


993 


c 


21345 


993 


c 


21557 


993 


c 


22226 


993 


c 


21346 


993 


c 


21600 


031 


c 


22230 


993 


c 


21347 


993 


c 


21610 


031 


c 


22305 


040 


c 


21348 


993 


c 


21615 


993 


c 


22310 


040 


c 


21355 


236 


c 


21616 


993 


c 


22315 


993 


c 


21356 


993 


c 


21620 


993 


c 


22325 


993 


c 


21360 


993 


c 


21627 


993 


c 


22326 


993 


c 


21365 


993 


c 


21630 


993 


c 


22327 


993 


c 


21366 


993 


c 


21632 


993 


c 


22328 


993 


c 


21385 


993 


c 


21633 


993 


c 


22505 


040 


c 


21386 


993 


c 


21700 


030 


c 


22548 


993 


c 


21387 


993 


c 


21705 


993 


c 


22554 


993 


c 


21390 


993 


c 


21720 


030 


c 


22556 


993 


c 


21395 


993 


c 


21725 


031 


c 


22558 


993 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



131 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


22585 


993 


C 


23107 


031 


C 


23515 


043 


C 


22590 


993 


C 


23120 


031 


C 


23520 


040 


C 


27595 


993 


C 


23125 


993 


C 


23525 


040 


C 


22600 


993 


C 


23130 


031 


C 


23530 


043 


C 


22610 


993 


C 


23140 


031 


C 


23532 


043 


C 


22612 


993 


C 


23145 


031 


C 


23540 


040 


C 


22614 


993 


C 


23146 


031 


C 


23545 


040 


C 


22625 


993 


C 


23150 


031 


C 


23550 


043 


C 


22630 


993 


C 


23155 


031 


C 


23552 


043 


C 


22632 


993 


C 


23156 


031 


C 


23570 


040 


C 


22650 . 


993 


C 


23170 


031 


C 


23575 


040 


C 


22800 - 


993 


C 


23172 


031 


C 


23585 


993 


C 


22802 


993 


C 


23174 


031 


C 


23600 


042 


C 


22804 


993 


C 


23180 


031 


C 


23605 


041 


C 


22808 


993 


c 


23182 


031 


C 


23615 


043 


C 


22810 


993 


c 


23184 


031 


c 


23616 


993 


C 


22812 


993 


c 


23190 


031 


C 


23620 


042 


C 


22820 


993 


c 


23195 


993 


C 


23625 


041 


C 


22830 


993 


c 


23200 


993 


c 


23630 


043 


C 


22840 


993 


c 


23210 


993 


C 


23650 


040 


C 


22841 


993 


c 


23220 


993 


C 


23655 


041 


C 


22842 


993 


c 


23221 


993 


C 


23660 


043 


C 


22843 


993 


c 


23222 


993 


C 


23665 


041 


C 


22844 


993 


c 


23330 


010 


C 


23670 


993 


c 


22845 


993 


c 


23331 


012 


C 


23675 


041 


c 


22846 


993 


c 


23332 


993 


C 


23680 


993 


c 


22847 


993 


c 


23350 


326 


C 


23700 


041 


c 


22848 


993 


c 


23395 


993 


C 


23800 


993 


c 


22849 


993 


c 


23397 


993 


C 


23802 


993 


c 


22850 


993 


c 


23400 


993 


C 


23900 


993 


c 


22851 


993 


c 


23405 


031 


C 


23920 


993 


c 


22852 


993 


c 


23406 


031 


C 


23921 


016 


c 


22855 


993 


c 


23410 


032 


C 


23929 


030 


c 


22899 


993 


c 


23412 


032 


c 


23930 


005 


c 


22900 


012 


c 


23415 


031 


C 


23931 


005 


c 


22999 


030 


c 


23420 


032 


C 


23935 


031 


c 


23000 


030 


c 


23430 


031 


c 


24000 


031 


c 


23020 


032 


c 


23440 


993 


C 


24006 


031 


c 


23030 


005 


c 


23450 


032 


C 


24065 


010 


c 


23031 


005 


c 


23455 


993 


C 


24066 


012 


c 


23035 


031 


c 


23460 


993 


C 


24075 


Oil 


c 


23040 


031 


c 


23462 


993 


C 


24076 


012 


c 


23044 


031 


c 


23465 


993 


C 


24077 


993 


c 


23065 


010 


c 


23466 


993 


C 


24100 


031 


c 


23066 


012 


c 


23470 


993 


C 


24101 


031 


c 


23075 


Oil 


c 


23472 


993 


C 


24102 


031 


c 


23076 


012 


c 


23480 


993 


C 


24105 


030 


c 


23077 


993 


c 


23485 


993 


C 


24110 


031 


c 


23100 


031 


c 


23490 


993 


C 


24115 


032 


c 


23101 


031 


c 


23491 


993 


C 


24116 


032 


c 


23105 


031 


c . 


23500 


040 


C 


24120 


031 


c 


23106 


031 


c 


23505 


040 


c 


24125 


031 


c 


132 














Final 


Report 



'tel»>> 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


24126 


032 


C 


24545 


993 


C 


25107 


031 


C 


24130 


031 


C 


24546 


043 


C 


25110 


030 


C 


24134 


031 


C 


24560 


042 


C 


25111 


033 


c 


24136 


031 


C 


24565 


042 


C 


25112 


033 


C 


24138 


031 


C 


24566 


043 


C 


25115 


031 


C 


24140 


031 


C 


24575 


993 


C 


25116 


031 


C 


24145 


031 


C 


24576 


042 


C 


25118 


030 


c 


24147 


031 


C 


24577 


041 


C 


25119 


031 


C 


24150 


993 


C 


24579 


043 


C 


25120 


031 


C 


24151 


993 


C 


24582 


043 


C 


25125 


032 


C 


24152 


. 993 


C 


24586 


993 


C 


25126 


032 


C 


24153 - 


■ 993 


C 


24587 


993 


C 


25130 


031 


C 


24155 


993 


C 


24600 


042 


C 


25135 


031 


C 


24160 


031 


C 


24605 


042 


C 


25136 


031 


C 


24164 


031 


C 


24615 


993 


C 


25145 


031 


C 


24200 


010 


c 


24620 


041 


C 


25150 


031 


C 


24201 


012 


c 


24635 


993 


C 


25151 


031 


C 


24220 


326 


c 


24640 


041 


C 


25170 


032 


C 


24301 


031 


c 


24650 


042 


C 


25210 


034 


C 


24305 


030 


c 


24655 


041 


C 


25215 


035 


C 


24310 


030 


c 


24665 


043 


C 


25230 


031 


C 


24320 


032 


c 


24666 


993 


C 


25240 


031 


C 


24330 


031 


c 


24670 


042 


C 


25246 


326 


C 


24331 


032 


c 


24675 


041 


C 


25248 


030 


C 


24340 


032 


c 


24685 


043 


C 


25250 


031 


C 


24342 


032 


c 


24800 


993 


C 


25251 


031 


C 


24350 


030 


c 


24802 


993 


C 


25260 


031 


c 


24351 


030 


c 


24900 


993 


C 


25263 


031 


c 


24352 


031 


c 


24920 


993 


C 


25265 


031 


C 


24354 


031 


c 


24925 


031 


C 


25270 


030 


C 


24356 


031 


c 


24930 


993 


C 


25272 


030 


C 


24360 


045 


c 


24931 


993 


C 


25274 


031 


C 


24361 


046 


c 


24935 


032 


C 


25280 


031 


C 


24362 


045 


c 


24940 


993 


C 


25290 


030 


C 


24363 


993 


c 


24999 


042 


c 


25295 


030 


C 


24365 


045 


c 


25000 


030 


c 


25300 


031 


C 


24366 


993 


c 


25005 


030 


c 


25301 


031 


C 


24400 


031 


c 


25020 


030 


c 


25310 


032 


C 


24410 


031 


c 


25023 


031 


c 


25312 


031 


C 


24420 


032 


c 


25028 


030 


c 


25315 


032 


C 


24430 


032 


c 


25031 


005 


c 


25316 


032 


C 


24435 


032 


c 


25035 


031 


c 


25317 


032 


C 


24470 


032 


c 


25040 


031 


c 


25318 


032 


C 


24495 


031 


c 


25065 


010 


c 


25320 


032 


C 


24498 


032 


c 


25066 


012 


c 


25330 


045 


C 


24500 


042 


c 


25075 


Oil 


c 


25331 


045 


C 


24505 


041 


c 


25076 


012 


c 


25332 


045 


C 


24515 


043 


c 


25077 


035 


c 


25335 


032 


C 


24516 


993 


c 


25085 


030 


c 


25337 


032 


C 


24530 


042 


c 


25100 


03! 


c 


25350 


032 


C 


24535 


041 


c 


25101 


031 


c 


25355 


031 


C 


24538 


043 


c 


25105 


031 


c 


25360 


032 


C 



The Development of a Physician Prospective Payment System for Ambulatory Care 



133 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


25365 


032 


C 


25670 


043 


C 


26145 


034 


C 


25370 


032 


C 


25675 


041 


C 


26160 


033 


C 


25375 


032 


c 


25676 


043 


C 


26170 


034 


C 


25390 


032 


c 


25680 


041 


C 


26180 


034 


C 


25391 


993 


c 


25685 


043 


C 


26200 


034 


C 


25392 


993 


c 


25690 


041 


C 


26205 


035 


C 


25393 


993 


c 


25695 


043 


c 


26210 


034 


C 


25400 


032 


c 


25800 


032 


C 


26215 


034 


C 


25405 


993 


c 


25805 


032 


C 


26230 


034 


C 


25415 


032 


c 


25810 


032 


c 


26235 


034 


C 


25420 


993 


c 


25820 


035 


C 


26236 


034 


C 


25425 - 


032 


c 


25825 


035 


C 


26250 


034 


C 


25426 


032 


c 


25830 


032 


c 


26255 


993 


C 


25440 


032 


c 


25900 


993 


c 


26260 


034 


C 


25441 


046 


c 


25905 


993 


C 


26261 


034 


C 


25442 


046 


c 


25907 


031 


c 


26262 


034 


C 


25443 


046 


c 


25909 


993 


c 


26320 


012 


C 


25444 


046 


c 


25915 


993 


C 


26350 


034 


C 


25445 


046 


c 


25920 


993 


c 


26352 


035 


C 


25446 


046 


c 


25922 


031 


c 


26356 


035 


C 


25447 


045 


c 


25924 


993 


C 


26357 


035 


C 


25449 


045 


c 


25927 


993 


c 


26358 


035 


C 


25450 


032 


c 


25929 


016 


c 


26370 


035 


C 


25455 


032 


c 


25931 


993 


C 


26372 


035 


C 


25490 


993 


c 


25999 


030 


c 


26373 


035 


C 


25491 


993 


c 


26010 


004 


c 


26390 


035 


c 


25492 


993 


c 


26011 


004 


c 


26392 


035 


C 


25500 


042 


c 


26020 


034 


c 


26410 


034 


C 


25505 


041 


c 


26025 


034 


c 


26412 


035 


C 


25515 


043 


c 


26030 


035 


C 


26415 


035 


C 


25520 


042 


c 


26034 


034 


c 


26416 


035 


c 


25525 


043 


c 


26035 


035 


C 


26418 


034 


C 


25526 


993 


c 


26037 


035 


c 


26420 


035 


C 


25530 


042 


c 


26040 


033 


C 


26426 


035 


C 


25535 


041 


c 


26045 


034 


C 


26428 


035 


c 


25545 


043 


c 


26055 


033 


C 


26432 


034 


C 


25560 


042 


c 


26060 


047 


C 


26433 


034 


C 


25565 


041 


c 


26070 


033 


c 


26434 


034 


C 


25574 


043 


c 


26075 


033 


c 


26437 


034 


C 


25575 


043 


c 


26080 


033 


c 


26440 


034 


C 


25600 


042 


c 


26100 


033 


C 


26442 


034 


C 


25605 


041 


c 


26105 


033 


C 


26445 


034 


C 


25611 


043 


c 


26110 


033 


c 


26449 


035 


C 


25620 


043 


c 


26115 


012 


C 


26450 


047 


C 


25622 


042 


c 


26116 


012 


C 


26455 


047 


C 


25624 


040 


c 


26117 


035 


c 


26460 


047 


C 


25628 


043 


c 


26121 


035 


C 


26471 


034 


C 


25630 


042 


c 


26123 


035 


C 


26474 


034 


C 


25635 


040 


c 


26125 


033 


C 


26476 


034 


C 


25645 


043 


c 


26130 


034 


C 


26477 


034 


C 


25650 


042 


c 


26135 


034 


c 


26478 


034 


C 


25660 


040 


c 


26140 


034 


c 


26479 


034 


C 


134 














Final 


Report 



■■^-V.riV 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


26480 


035 


C 


26605 


040 


C 


27003 


031 


C 


26483 


035 


C 


26607 


040 


C 


27005 


993 


C 


26485 


035 


C 


26608 


043 


C 


27006 


993 


c 


26489 


035 


C 


26615 


043 


C 


27025 


993 


c 


26490 


035 


C 


26641 


040 


C 


27030 


993 


c 


26492 


035 


C 


26645 


040 


c 


27033 


993 


c 


26494 


035 


C 


26650 


043 


c 


27035 


993 


c 


26496 


035 


c 


26665 


043 


c 


27040 


Oil 


c 


26497 


035 


c 


26670 


040 


C 


27041 


012 


c 


26498 


035 


c 


26675 


040 


C 


27047 


012 


c 


26499 


. 035 


c 


26676 


043 


C 


27048 


012 


c 


26500 - 


034 


c 


26685 


043 


c 


27049 


993 


c 


26502 


035 


c 


26686 


043 


C 


27050 


030 


c 


26504 


035 


c 


26700 


040 


C 


27052 


031 


c 


26508 


034 


c 


26705 


040 


C 


27054 


993 


c 


26510 


034 


c 


26706 


043 


C 


27060 


030 


c 


26516 


034 


c 


26715 


043 


C 


27062 


030 


c 


26517 


035 


c 


26720 


040 


C 


27065 


030 


c 


26518 


035 


c 


26725 


040 


C 


27066 


031 


c 


26520 


034 


c 


26727 


043 


C 


27067 


032 


c 


26525 


033 


c 


26735 


043 


c 


27070 


031 


c 


26527 


045 


c 


26740 


040 


C 


27071 


993 


c 


26530 


045 


c 


26742 


040 


C 


27075 


993 


c 


26531 


046 


c 


26746 


043 


C 


27076 


993 


c 


26535 


045 


c 


26750 


040 


C 


27077 


993 


c 


26536 


046 


c 


26755 


040 


C 


27078 


993 


c 


26540 


035 


c 


26756 


043 


c 


27079 


993 


c 


26541 


035 


c 


26765 


043 


C 


27080 


031 


c 


26542 


035 


c 


26770 


040 


C 


27086 


010 


c 


26545 


035 


c 


26775 


040 


c 


27087 


030 


c 


26548 


035 


c 


26776 


043 


C 


27090 


993 


c 


26550 


035 


c 


26785 


043 


C 


27091 


993 


c 


26552 


035 


c 


26820 


035 


c 


27093 


326 


c 


26555 


035 


c 


26841 


035 


C 


27095 


326 


c 


26557 


035 


c 


26842 


035 


C 


27097 


031 


c 


26558 


035 


c 


26843 


035 


c 


27098 


031 


c 


26559 


035 


c 


26844 


035 


C 


27100 


032 


c 


26560 


034 


c 


26850 


035 


C 


27105 


032 


c 


26561 


035 


c 


26852 


035 


c 


27110 


032 


c 


26562 


035 


c 


26860 


034 


C 


27111 


032 


c 


26565 


035 


c 


26861 


033 


C 


27120 


993 


c 


26567 


034 


c 


26862 


035 


C 


27122 


993 


c 


26568 


035 


c 


26863 


033 


c 


27125 


993 


c 


26580 


035 


c 


26910 


035 


c 


27130 


993 


c 


26585 


035 


c 


26951 


034 


c 


27132 


993 


c 


26587 


034 


c 


26952 


034 


c 


27134 


993 


c 


26590 


035 


c 


26989 


033 


C 


27137 


993 


c 


26591 


033 


c 


26990 


030 


c 


27138 


993 


c 


26593 


034 


c 


26991 


030 


c 


27140 


993 


c 


26596 


035 


c 


26992 


032 


c 


27146 


032 


c 


26597 


035 


c 


27000 


030 


c 


27147 


993 


c 


26600 


040 


c 


27001 


030 


C 


27151 


993 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



135 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


27156 


993 


C 


27295 


993 


C 


27424 


032 


C 


27158 


993 


C 


27299 


030 


C 


27425 


031 


C 


27161 


993 


c 


27301 


005 


C 


27427 


032 


C 


27165 


993 


c 


27303 


031 


C 


27428 


032 


C 


27170 


993 


c 


27305 


030 


C 


27429 


032 


C 


27175 


993 


c 


27306 


030 


C 


27430 


032 


C 


27176 


993 


c 


27307 


030 


C 


27435 


032 


C 


27177 


993 


c 


27310 


031 


C 


27437 


045 


C 


27178 


993 


c 


27315 


197 


C 


27438 


993 


C 


27179 


993 


c 


27320 


197 


C 


27440 


045 


C 


27181 


. 993 


c 


27323 


Oil 


c 


27441 


045 


C 


27185 - 


■ 993 


c 


27324 


012 


c 


27442 


045 


C 


27187 


993 


c 


27327 


012 


c 


27443 


045 


C 


27193 


042 


c 


27328 


012 


c 


27445 


993 


C 


27194 


041 


c 


27329 


993 


c 


27446 


993 


C 


27200 


040 


c 


27330 


031 


c 


27447 


993 


C 


27202 


043 


c 


27331 


031 


c 


27448 


993 


C 


27215 


993 


c 


27332 


031 


c 


27450 


993 


C 


27216 


993 


c 


27333 


031 


c 


27454 


993 


C 


27217 


993 


c 


27334 


031 


c 


27455 


993 


C 


27218 


993 


c 


27335 


031 


c 


27457 


993 


C 


27220 


042 


c 


27340 


030 


c 


27465 


993 


C 


27222 


993 


c 


27345 


031 


c 


27466 


993 


C 


27226 


993 


c 


27350 


031 


c 


27468 


993 


C 


27227 


993 


c 


27355 


031 


c 


27470 


993 


C 


27228 


993 


c 


27356 


031 


c 


27472 


993 


C 


27230 


042 


c 


27357 


031 


c 


27475 


993 


C 


27232 


993 


c 


27358 


031 


c 


27477 


993 


C 


27235 


993 


c 


27360 


031 


c 


27479 


993 


C 


27236 


993 


c 


27365 


993 


c 


27485 


993 


C 


27238 


042 


c 


27370 


326 


c 


27486 


993 


C 


27240 


993 


c 


27372 


012 


c 


27487 


993 


c 


27244 


993 


c 


27380 


993 


c 


27488 


993 


c 


27245 


993 


c 


27381 


993 


c 


27495 


993 


c 


27246 


042 


c 


27385 


993 


c 


27496 


031 


c 


27248 


993 


c 


27386 


993 


c 


27497 


030 


c 


27250 


042 


c 


27390 


031 


c 


27498 


031 


c 


27252 


042 


c 


27391 


031 


c 


27499 


031 


c 


27253 


993 


c 


27392 


031 


c 


27500 


042 


c 


27254 


993 


c 


27393 


031 


c 


27501 


042 


c 


27256 


042 


c 


27394 


031 


c 


27502 


042 


c 


27257 


042 


c 


27395 


032 


c 


27503 


041 


c 


27258 


993 


c 


27396 


031 


c 


27506 


993 


c 


27259 


993 


c 


27397 


032 


c 


27507 


993 


c 


27265 


042 


c 


27400 


032 


c 


27508 


042 


c 


27266 


042 


c 


27403 


031 


c 


27509 


993 


c 


27275 


041 


c 


27405 


032 


c 


27510 


041 


c 


27280 


032 


c 


27407 


032 


c 


27511 


993 


c 


27282 


032 


c 


27409 


032 


c 


27513 


993 


c 


27284 


993 


c 


27418 


032 


c 


27514 


993 


c 


27286 


993 


c 


27420 


032 


c 


27516 


042 


c 


27290 


993 


c 


27422 


032 


c 


275)7 


041 


c 


136 














Final Report 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


27519 


993 


C 


27647 


032 


C 


27781 


041 


C 


27520 


042 


C 


27648 


326 


C 


27784 


993 


C 


27524 


043 


c 


27650 


032 


C 


27786 


042 


C 


27530 


042 


c 


27652 


032 


C 


27788 


041 


C 


27532 


042 


c 


27654 


032 


C 


27792 


043 


C 


27535 


993 


c 


27656 


030 


C 


27808 


042 


C 


27536 


993 


c 


27658 


030 


C 


27810 


041 


C 


27538 


042 


c 


27659 


031 


C 


27814 


043 


C 


27540 


993 


c 


27664 


030 


c 


27816 


042 


c 


27550 


042 


c 


27665 


030 


C 


27818 


041 


C 


27552 


. 042 


c 


27675 


031 


C 


27822 


043 


C 


27556 - 


993 


c 


27676 


031 


C 


27823 


043 


C 


27557 


993 


c 


27680 


030 


C 


27824 


042 


C 


27558 


993 


c 


27681 


030 


C 


27825 


041 


C 


27560 


042 


c 


27685 


030 


c 


27826 


043 


c 


27562 


042 


c 


27686 


030 


C 


27827 


043 


C 


27566 


993 


c 


27687 


031 


C 


27828 


043 


c 


27570 


042 


c 


27690 


035 


C 


27829 


043 


C 


27580 


993 


c 


27691 


035 


C 


27830 


042 


C 


27590 


993 


c 


27692 


030 


C 


27831 


042 


C 


27591 


993 


c 


27695 


031 


C 


27832 


993 


C 


27592 


993 


c 


27696 


031 


C 


27840 


042 


C 


27594 


030 


c 


27698 


031 


C 


27842 


042 


c 


27596 


993 


c 


27700 


045 


C 


27846 


993 


C 


27598 


993 


c 


27702 


993 


C 


27848 


043 


C 


27599 


030 


c 


27703 


993 


C 


27860 


041 


c 


27600 


030 


c 


27704 


031 


C 


27870 


032 


c 


27601 


030 


c 


27705 


032 


C 


27871 


032 


c 


27602 


030 


c 


27707 


030 


C 


27880 


993 


C 


27603 


005 


c 


27709 


031 


C 


27881 


993 


c 


27604 


005 


c 


27712 


993 


C 


27882 


993 


C 


27605 


033 


c 


27715 


993 


C 


27884 


030 


C 


27606 


030 


c 


27720 


993 


c 


27886 


993 


c 


27607 


031 


c 


27722 


993 


c 


27888 


993 


C 


27610 


031 


c 


27724 


993 


C 


27889 


031 


C 


27612 


031 


c 


27725 


993 


c 


27892 


030 


c 


27613 


010 


c 


27727 


993 


C 


27893 


030 


c 


27614 


012 


c 


27730 


031 


C 


27894 


030 


c 


27615 


993 


c 


27732 


031 


C 


27899 


033 


C 


27618 


012 


c 


27734 


031 


C 


28001 


005 


C 


27619 


031 


c 


27740 


031 


C 


28002 


034 


C 


27620 


031 


c 


27742 


032 


C 


28003 


034 


c 


27625 


031 


c 


27745 


032 


C 


28005 


034 


c 


27626 


031 


c 


27750 


042 


c 


28008 


033 


c 


27630 


030 


c 


27752 


041 


c 


28010 


047 


c 


27635 


031 


c 


27756 


993 


c 


28011 


047 


c 


27637 


032 


c 


27758 


993 


c 


28020 


034 


c 


27638 


032 


c 


27759 


993 


C 


28022 


033 


c 


27640 


032 


c 


27760 


042 


c 


28024 


033 


c 


27641 


031 


c 


21162 


04] 


c 


28030 


197 


c 


27645 


032 


c 


27766 


043 


c 


28035 


197 


c 


27646 


993 


c 


27780 


042 


c 


28043 


Oil 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



137 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


28045 


034 


C 


28230 


047 


C 


28445 


993 


C 


28046 


993 


c 


28232 


047 


C 


28450 


040 


C 


28050 


033 


c 


28234 


047 


C 


28455 


040 


c 


28052 


033 


c 


28236 


035 


C 


28456 


043 


C 


28054 


033 


c 


28238 


035 


c 


28465 


043 


C 


28060 


034 


c 


28240 


047 


C 


28470 


040 


C 


28062 


035 


c 


28250 


034 


C 


28475 


040 


C 


28070 


034 


c 


28260 


035 


C 


28476 


043 


C 


28072 


034 


c 


28261 


035 


C 


28485 


043 


C 


28080 


033 


c 


28262 


035 


C 


28490 


040 


C 


28086 


. 033 


c 


28264 


035 


C 


28495 


040 


C 


28088 


. 033 


c 


28270 


033 


c 


28496 


043 


C 


28090 


033 


c 


28272 


033 


c 


28505 


043 


C 


28092 


033 


c 


28280 


033 


c 


28510 


040 


C 


28100 


034 


c 


28285 


034 


c 


28515 


040 


C 


28102 


035 


c 


28286 


034 


c 


28525 


043 


C 


28103 


034 


c 


28288 


034 


c 


28530 


040 


C 


28104 


034 


c 


28290 


044 


c 


28531 


043 


C 


28106 


035 


c 


28292 


044 


c 


28540 


040 


C 


28107 


034 


c 


28293 


044 


c 


28545 


040 


C 


28108 


033 


c 


28294 


044 


c 


28546 


043 


C 


28110 


033 


c 


28296 


044 


c 


28555 


043 


C 


28111 


034 


c 


28297 


044 


c 


28570 


040 


C 


28112 


034 


c 


28298 


044 


c 


28575 


040 


C 


28113 


034 


c 


28299 


044 


c 


28576 


043 


C 


28114 


035 


c 


28300 


035 


c 


28585 


043 


C 


28116 


034 


c 


28302 


035 


c 


28600 


040 


C 


28118 


034 


c 


28304 


035 


c 


28605 


040 


C 


28119 


034 


c 


28305 


035 


c 


28606 


043 


C 


28120 


034 


c 


28306 


034 


c 


28615 


043 


C 


28122 


034 


c 


28307 


034 


c 


28630 


040 


C 


28124 


034 


c 


28308 


034 


c 


28635 


040 


c 


28126 


033 


c 


28309 


035 


c 


28636 


043 


C 


28130 


035 


c 


28310 


034 


c 


28645 


043 


c 


28140 


034 


c 


28312 


034 


c 


28660 


040 


C 


28150 


033 


c 


28313 


033 


c 


28665 


040 


C 


28153 


033 


c 


28315 


034 


c 


28666 


043 


C 


28160 


033 


c 


28320 


035 


c 


28675 


043 


C 


28171 


033 


c 


28322 


035 


c 


28705 


035 


C 


28173 


035 


c 


28340 


034 


c 


28715 


035 


C 


28175 


034 


c 


28341 


035 


c 


28725 


035 


c 


28190 


010 


c 


28344 


033 


c 


28730 


035 


C 


28192 


012 


c 


28345 


034 


c 


28735 


035 


C 


28193 


012 


c 


28360 


035 


c 


28737 


035 


C 


28200 


034 


c 


28400 


040 


c 


28740 


034 


C 


28202 


035 


c 


28405 


040 


c 


28750 


034 


c 


28208 


033 


c 


28406 


043 


c 


28755 


034 


C 


28210 


035 


c 


28415 


043 


c 


28760 


034 


C 


28220 


034 


c 


28420 


043 


c 


28800 


993 


C 


28222 


034 


c 


28430 


040 


c 


28805 


993 


C 


28225 


033 


c 


28435 


040 


c 


28810 


034 


C 


28226 


034 


c 


28436 


043 


c 


28820 


033 


C 


138 














Final 


Report 



*VVi|) 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


28825 


033 


C 


29730 


038 


C 


29909 


036 


C 


28899 


033 


C 


29740 


037 


C 


30000 


233 


C 


29000 


037 


c 


29750 


037 


C 


30020 


233 


C 


29010 


037 


c 


29799 


038 


C 


30100 


233 


c 


29015 


037 


c 


29800 


036 


C 


30110 


233 


c 


29020 


037 


c 


29804 


036 


C 


30115 


234 


c 


29025 


037 


c 


29815 


036 


C 


30117 


234 


c 


29035 


037 


c 


29819 


036 


C 


30118 


235 


C 


29040 


037 


c 


29820 


036 


C 


30120 


234 


c 


29044 


037 


c 


29821 


036 


C 


30124 


233 


C 


29046 . 


037 


c 


29822 


036 


C 


30125 


235 


C 


29049 - 


037 


c 


29823 


036 


C 


30130 


234 


c 


29055 


037 


c 


29825 


036 


c 


30140 


234 


C 


29058 


037 


c 


29826 


036 


C 


30150 


235 


C 


29065 


037 


c 


29830 


036 


C 


30160 


235 


C 


29075 


037 


c 


29834 


036 


C 


30200 


326 


C 


29085 


037 


c 


29835 


036 


c 


30210 


233 


C 


29105 


038 


c 


29836 


036 


c 


30220 


233 


c 


29125 


038 


c 


29837 


036 


C 


30300 


233 


c 


29126 


038 


c 


29838 


036 


c 


30310 


233 


C 


29130 


038 


c 


29840 


036 


C 


30320 


233 


c 


29131 


038 


c 


29843 


036 


c 


30400 


236 


C 


29200 


038 


c 


29844 


036 


c 


30410 


236 


C 


29220 


038 


c 


29845 


036 


C 


30420 


236 


c 


29240 


038 


c 


29846 


036 


c 


30430 


235 


C 


29260 


038 


c 


29847 


036 


c 


30435 


236 


C 


29280 


038 


c 


29848 


036 


C 


30450 


236 


C 


29305 


037 


c 


29850 


036 


C 


30460 


236 


c 


29325 


037 


c 


29851 


036 


c 


30462 


236 


c 


29345 


037 


c 


29855 


036 


C 


30520 


235 


C 


29355 


037 


c 


29856 


036 


c 


30540 


235 


C 


29358 


037 


c 


29870 


036 


c 


30545 


235 


C 


29365 


037 


c 


29871 


036 


C 


30560 


233 


C 


29405 


037 


c 


29874 


036 


c 


30580 


235 


C 


29425 


037 


c 


29875 


036 


C 


30600 


235 


c 


29435 


037 


c 


29876 


036 


C 


30620 


235 


C 


29440 


038 


c 


29877 


036 


c 


30630 


235 


C 


29445 


037 


c 


29879 


036 


c 


30801 


233 


C 


29450 


037 


c 


29880 


036 


c 


30802 


233 


c 


29505 


038 


c 


29881 


036 


c 


30901 


232 


c 


29515 


038 


c 


29882 


036 


c 


30903 


232 


C 


29520 


038 


c 


29883 


036 


c 


30905 


232 


c 


29530 


038 


c 


29884 


036 


C 


30906 


232 


c 


29540 


038 


c 


29885 


036 


c 


30915 


084 


c 


29550 


038 


c 


29886 


036 


c 


30920 


084 


c 


29580 


039 


c 


29887 


036 


c 


30930 


233 


c 


29590 


038 


c 


29888 


036 


c 


30999 


233 


c 


29700 


038 


c 


29889 


036 


c 


31000 


233 


C 


29705 


038 


c 


29894 


036 


c 


31002 


233 


c 


29710 


038 


c 


29895 


036 


c 


31020 


234 


c 


29715 


038 


c 


29897 


036 


c 


31030 


235 


c 


29720 


038 


c 


29898 


036 


c 


31032 


235 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



139 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


31040 


235 


C 


31280 


061 


C 


31571 


061 


C 


31050 


235 


C 


31281 


061 


C 


31575 


059 


C 


31051 


235 


C 


31282 


061 


C 


31576 


060 


C 


31070 


235 


C 


31283 


061 


c 


31577 


060 


C 


31071 


234 


C 


31284 


061 


c 


31578 


060 


C 


31075 


236 


C 


31285 


060 


c 


31579 


060 


C 


31080 


236 


C 


31286 


061 


c 


31580 


236 


C 


31081 


993 


C 


31287 


060 


c 


31582 


993 


C 


31084 


236 


C 


31288 


061 


C 


31584 


993 


C 


31085 


993 


C 


31290 


993 


c 


31585 


234 


C 


31086 


. 236 


C 


31291 


993 


c 


31586 


234 


c 


31087 . 


. 993 


C 


31292 


993 


C 


31587 


993 


C 


31090 


236 


C 


31293 


993 


c 


31588 


236 


c 


31200 


235 


C 


31294 


993 


c 


31590 


235 


C 


31201 


235 


C 


31299 


233 


c 


31595 


235 


C 


31205 


235 


C 


31300 


236 


c 


31599 


233 


C 


31225 


993 


C 


31320 


235 


c 


31600 


234 


C 


31230 


993 


c 


31360 


993 


C 


31601 


234 


C 


31231 


059 


c 


31365 


993 


C 


31603 


234 


C 


31233 


060 


c 


31367 


993 


C 


31605 


234 


c 


31235 


060 


c 


31368 


993 


C 


31610 


235 


C 


31237 


060 


c 


31370 


993 


c 


31611 


235 


C 


31238 


060 


c 


31375 


236 


c 


31612 


058 


C 


31239 


061 


c 


31380 


993 


C 


31613 


234 


C 


31240 


060 


c 


31382 


993 


c 


31614 


235 


C 


31245 


060 


c 


31390 


993 


c 


31615 


062 


c 


31246 


061 


c 


31395 


993 


c 


31622 


062 


C 


31247 


061 


c 


31400 


235 


c 


31625 


062 


C 


31248 


061 


c 


31420 


236 


c 


31628 


062 


C 


31249 


061 


c 


31500 


087 


C 


31629 


062 


C 


31250 


059 


c 


31502 


325 


c 


31630 


062 


c 


31251 


061 


c 


31505 


421 


c 


31631 


062 


C 


31252 


060 


c 


31510 


059 


C 


31635 


062 


c 


31254 


061 


c 


31511 


059 


c 


31640 


062 


c 


31255 


061 


c 


31512 


060 


c 


31641 


062 


C 


31256 


060 


c 


31513 


059 


c 


31645 


062 


c 


31258 


060 


c 


31515 


059 


c 


31646 


062 


C 


31260 


060 


c 


31520 


059 


c 


31656 


062 


C 


31261 


061 


c 


31525 


059 


C 


31659 


062 


C 


31262 


061 


c 


31526 


060 


c 


31700 


058 


C 


31263 


060 


c 


31527 


060 


c 


31708 


326 


C 


31264 


061 


c 


31528 


060 


c 


31710 


058 


C 


31265 


060 


c 


31529 


060 


c 


31715 


058 


c 


31266 


061 


c 


31530 


060 


c 


31717 


058 


c 


31267 


061 


c 


31531 


060 


C 


31720 


233 


c 


31268 


060 


c 


31535 


060 


c 


31725 


993 


c 


31269 


061 


c 


31536 


060 


c 


31730 


058 


c 


31270 


060 


c 


31540 


061 


c 


31750 


236 


C 


31271 


061 


c 


31541 


061 


C 


31755 


236 


C 


31275 


060 


c 


31560 


061 


c 


31760 


993 


C 


31276 


061 


c 


31561 


061 


c 


31766 


993 


C 


31277 


061 


c 


31570 


061 


c 


31770 


993 


C 


140 














Final 


Report 



A'-r 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


31775 


993 


C 


32522 


993 


C 


33120 


993 


C 


31780 


993 


C 


32525 


993 


C 


33130 


993 


C 


31781 


993 


C 


32540 


993 


c 


33200 


993 


C 


31785 


993 


C 


32545 


993 


c 


33201 


993 


C 


31786 


993 


C 


32601 


993 


c 


33206 


081 


C 


31800 


993 


C 


32602 


993 


C 


33207 


081 


C 


31805 


993 


C 


32603 


993 


c 


33208 


081 


C 


31820 


234 


C 


32604 


993 


C 


33210 


083 


C 


31825 


235 


C 


32605 


993 


C 


33211 


993 


C 


31830 


234 


C 


32606 


993 


C 


33212 


081 


C 


31899 


. 233 


C 


32650 


993 


c 


33213 


081 


C 


32000 . 


" 058 


C 


32651 


993 


c 


33214 


081 


C 


32002 


058 


C 


32652 


993 


c 


33216 


083 


C 


32005 


993 


C 


32653 


993 


C 


33217 


083 


C 


32020 


058 


C 


32654 


993 


c 


33218 


083 


C 


32035 


993 


C 


32655 


993 


C 


33219 


081 


C 


32036 


993 


C 


32656 


993 


C 


33220 


083 


C 


32095 


993 


C 


32657 


993 


c 


33222 


016 


C 


32100 


993 


C 


32658 


993 


c 


33223 


016 


C 


32110 


993 


C 


32659 


993 


C 


33232 


083 


C 


32120 


993 


C 


32660 


993 


C 


33233 


083 


C 


32124 


993 


C 


32661 


993 


C 


33234 


083 


C 


32140 


993 


C 


32662 


993 


C 


33235 


083 


C 


32141 


993 


C 


32663 


993 


c 


33236 


993 


C 


32150 


993 


C 


32664 


993 


C 


33237 


993 


C 


32151 


993 


C 


32665 


993 


C 


33238 


993 


C 


32160 


993 


C 


32700 


993 


C 


33240 


081 


C 


32200 


993 


C 


32705 


993 


c 


33241 


083 


C 


32215 


993 


C 


32800 


993 


c 


33242 


083 


C 


32220 


993 


C 


32810 


993 


C 


33243 


993 


c 


32225 


993 


c 


32815 


993 


c 


33244 


083 


C 


32310 


993 


C 


32820 


993 


C 


33245 


993 


c 


32315 


993 


C 


32850 


993 


C 


33246 


993 


C 


32320 


993 


C 


32851 


993 


c 


33247 


083 


C 


32400 


003 


C 


32852 


993 


C 


33248 


993 


C 


32402 


993 


c 


32853 


993 


C 


33249 


081 


C 


32405 


003 


c 


32854 


993 


C 


33250 


993 


C 


32420 


058 


C 


32900 


993 


c 


33251 


993 


c 


32440 


993 


C 


32905 


993 


c 


33253 


993 


C 


32442 


993 


C 


32906 


993 


C 


33260 


993 


C 


32445 


993 


C 


32940 


993 


c 


33261 


993 


C 


32450 


993 


C 


32960 


058 


C 


33300 


993 


C 


32480 


993 


C 


32999 


058 


C 


33305 


993 


C 


32482 


993 


c 


33010 


058 


c 


33310 


993 


C 


32484 


993 


C 


33011 


058 


C 


33315 


993 


c 


32485 


993 


c 


33015 


993 


c 


33320 


993 


c 


32486 


993 


C 


33020 


993 


c 


33321 


993 


C 


32488 


993 


C 


33025 


993 


c 


33322 


993 


C 


32490 


993 


c 


33030 


993 


c 


33330 


993 


C 


32500 


993 


C 


33031 


993 


c 


33332 


993 


C 


32501 


993 


C 


33050 


993 


c 


33335 


993 


C 


32520 


993 


C 


33100 


993 


c 


33350 


993 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



141 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


33400 


993 


C 


33523 


993 


C 


33766 


993 


C 


33401 


993 


C 


33530 


993 


c 


33767 


993 


C 


33403 


993 


C 


33533 


993 


C 


33770 


993 


C 


33404 


993 


C 


33534 


993 


C 


33771 


993 


C 


33405 


993 


C 


33535 


993 


C 


33774 


993 


C 


33406 


993 


C 


33536 


993 


C 


33775 


993 


C 


33407 


993 


C 


33542 


993 


c 


33776 


993 


C 


33408 


993 


C 


33545 


993 


c 


33777 


993 


C 


33411 


993 


C 


33570 


993 


c 


33778 


993 


C 


33412 


993 


C 


33572 


993 


c 


33779 


993 


C 


33413 . 


993 


c 


33575 


993 


c 


33780 


993 


C 


33414/ 


993 


c 


33600 


993 


c 


33781 


993 


c 


33415 


993 


c 


33602 


993 


c 


33786 


993 


C 


33416 


993 


c 


33606 


993 


c 


33788 


993 


C 


33417 


993 


c 


33608 


993 


c 


33800 


993 


C 


33420 


993 


c 


33610 


993 


c 


33802 


993 


C 


33422 


993 


c 


33611 


993 


c 


33803 


993 


C 


33425 


993 


c 


33612 


993 


c 


33813 


993 


C 


33426 


993 


c 


33615 


993 


c 


33814 


993 


C 


33427 


993 


c 


33617 


993 


c 


33820 


993 


C 


33430 


993 


c 


33619 


993 


c 


33822 


993 


C 


33452 


993 


c 


33641 


993 


c 


33824 


993 


C 


33460 


993 


c 


33645 


993 


c 


33830 


993 


C 


33463 


993 


c 


33647 


993 


c 


33840 


993 


C 


33464 


993 


c 


33649 


993 


c 


33845 


993 


C 


33465 


993 


c 


33660 


993 


c 


33851 


993 


C 


33468 


993 


c 


33665 


993 


c 


33852 


993 


C 


33470 


993 


c 


33670 


993 


c 


33853 


993 


C 


33471 


993 


c 


33681 


993 


c 


33855 


993 


C 


33472 


993 


c 


33684 


993 


c 


33860 


993 


C 


33474 


993 


c 


33688 


993 


c 


33861 


993 


C 


33475 


993 


c 


33690 


993 


c 


33863 


993 


C 


33476 


993 


c 


33692 


993 


c 


33865 


993 


C 


33478 


993 


c 


33694 


993 


c 


33870 


993 


C 


33500 


993 


c 


33696 


993 


c 


33875 


993 


C 


33501 


993 


c 


33697 


993 


c 


33877 


993 


C 


33502 


993 


c 


33698 


993 


c 


33910 


993 


C 


33503 


993 


c 


33702 


993 


c 


33915 


993 


C 


33504 


993 


c 


33710 


993 


c 


33916 


993 


C 


33505 


993 


c 


33720 


993 


c 


33917 


993 


C 


33506 


993 


c 


33722 


993 


c 


33918 


993 


C 


33510 


993 


c 


33730 


993 


c 


33919 


993 


C 


33511 


993 


c 


33732 


993 


c 


33920 


993 


C 


33512 


993 


c 


33735 


993 


c 


33922 


993 


C 


33513 


993 


c 


33736 


993 


c 


33924 


993 


C 


33514 


993 


c 


33737 


993 


c 


33930 


993 


C 


33516 


993 


c 


33738 


993 


c 


33935 


993 


C 


33517 


993 


c 


33739 


993 


c 


33940 


993 


C 


33518 


993 


c 


33750 


993 


c 


33945 


993 


C 


33519 


993 


c 


33755 


993 


c 


33960 


993 


C 


33521 


993 


c 


33762 


993 


c 


33961 


993 


c 


33522 


993 


c 


33764 


993 


c 


33970 


993 


c 


142 














Final 


Report 



*'-;v 



o 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


33971 


993 


C 


35180 


086 


C 


35480 


993 


C 


33972 


993 


C 


35182 


993 


C 


35481 


993 


C 


33973 


993 


c 


35184 


086 


C 


35482 


079 


C 


33974 


993 


c 


35188 


086 


C 


35483 


079 


C 


33975 


993 


c 


35189 


993 


C 


35484 


079 


C 


33976 


993 


c 


35190 


086 


c 


35485 


079 


C 


33977 


993 


c 


35201 


993 


c 


35490 


079 


C 


33978 


993 


c 


35206 


086 


c 


35491 


079 


C 


33999 


993 


c 


35207 


086 


c 


35492 


079 


C 


34001 


993 


c 


35211 


993 


c 


35493 


079 


C 


34051 . 


993 


c 


35216 


993 


c 


35494 


079 


C 


34101 - 


079 


c 


35221 


993 


c 


35495 


079 


C 


34111 


993 


c 


35226 


086 


c 


35501 


993 


C 


34151 


993 


c 


35231 


993 


c 


35506 


993 


C 


34201 


993 


c 


35236 


086 


c 


35507 


993 


C 


34203 


993 


c 


35241 


993 


c 


35508 


993 


C 


34401 


993 


c 


35246 


993 


c 


35509 


993 


C 


34421 


993 


c 


35251 


993 


c 


35511 


993 


c 


34451 


993 


c 


35256 


086 


c 


35515 


993 


C 


34471 


993 


c 


35261 


993 


c 


35516 


993 


C 


34490 


086 


c 


35266 


086 


c 


35518 


993 


C 


34501 


086 


c 


35271 


993 


c 


35521 


993 


C 


34502 


993 


c 


35276 


993 


c 


35526 


993 


C 


34510 


086 


c 


35281 


993 


c 


35531 


993 


c 


34520 


086 


c 


35286 


086 


c 


35533 


993 


c 


34530 


086 


c 


35301 


993 


c 


35536 


993 


C 


35001 


993 


c 


35311 


993 


c 


35541 


993 


C 


35002 


993 


c 


35321 


993 


c 


35546 


993 


C 


35005 


993 


c 


35331 


993 


c 


35548 


993 


C 


35011 


993 


c 


35341 


993 


c 


35549 


993 


C 


35013 


993 


c 


35351 


993 


c 


35551 


993 


C 


35021 


993 


c 


35355 


993 


c 


35556 


993 


C 


35022 


993 


c 


35361 


993 


c 


35558 


993 


C 


35045 


086 


c 


35363 


993 


c 


35560 


993 


C 


35081 


993 


c 


35371 


993 


c 


35563 


993 


C 


35082 


993 


c 


35372 


993 


c 


35565 


993 


C 


35091 


993 


c 


35381 


993 


c 


35566 


993 


c 


35092 


993 


c 


35390 


993 


c 


35571 


993 


C 


35102 


993 


c 


35450 


079 


c 


35582 


993 


C 


35103 


993 


c 


35452 


079 


c 


35583 


993 


C 


35111 


993 


c 


35454 


079 


c 


35585 


993 


C 


35112 


993 


c 


35456 


079 


c 


35587 


993 


C 


35121 


993 


c 


35458 


079 


c 


35601 


993 


C 


35122 


993 


c 


35459 


079 


c 


35606 


993 


c 


35131 


993 


c 


35460 


080 


c 


35612 


993 


C 


35132 


993 


c 


35470 


079 


c 


35616 


993 


c 


35141 


993 


c 


35471 


079 


c 


35621 


993 


c 


35142 


993 


c 


35472 


079 


c 


35623 


993 


c 


35151 


993 


c 


35473 


079 


c 


35626 


993 


c 


35152 


993 


c 


35474 


079 


c 


35631 


993 


C 


35161 


993 


c 


35475 


079 


c 


35636 


993 


C 


35162 


993 


c 


35476 


080 


c 


35637 


993 


C 



The Development of a Physician Prospective Payment System for Ambulatory Care 



143 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


35638 


993 


C 


36216 


093 


C 


36815 


082 


C 


35641 


993 


C 


36217 


093 


C 


36820 


082 


C 


35642 


993 


C 


36218 


326 


C 


36821 


086 


C 


35645 


993 


C 


36230 


093 


C 


36822 


993 


C 


35646 


993 


C 


36245 


093 


C 


36825 


086 


C 


35650 


993 


C 


36246 


093 


C 


36830 


086 


C 


35651 


993 


C 


36247 


093 


C 


36832 


086 


C 


35654 


993 


C 


36248 


326 


C 


36834 


993 


C 


35656 


993 


C 


36260 


082 


C 


36835 


082 


C 


35661 


993 


C 


36261 


083 


C 


36840 


082 


C 


35663 


. 993 


C 


36262 


083 


C 


36845 


082 


C 


35665 . 


. 993 


C 


36299 


326 


C 


36860 


083 


C 


35666 


993 


C 


36400 


091 


C 


36861 


083 


C 


35671 


993 


C 


36405 


091 


C 


37140 


993 


C 


35681 


993 


C 


36406 


091 


C 


37145 


993 


C 


35691 


993 


C 


36410 


091 


C 


37160 


993 


C 


35693 


993 


C 


36415 


090 


C 


37180 


993 


C 


35694 


993 


C 


36420 


091 


C 


37181 


993 


C 


35695 


993 


C 


36425 


091 


C 


37190 


082 


C 


35700 


993 


C 


36430 


101 


C 


37200 


079 


C 


35701 


993 


C 


36440 


101 


C 


37201 


080 


C 


35721 


086 


C 


36450 


100 


C 


37202 


080 


C 


35741 


086 


c 


36455 


100 


C 


37203 


079 


C 


35761 


086 


C 


36460 


100 


C 


37204 


079 


c 


35800 


993 


C 


36468 


085 


c 


37205 


079 


C 


35820 


993 


c 


36469 


085 


C 


37206 


079 


c 


35840 


993 


C 


36470 


085 


C 


37207 


993 


C 


35860 


993 


C 


36471 


085 


C 


37208 


993 


c 


35870 


993 


C 


36481 


124 


c 


37209 


993 


C 


35875 


086 


c 


36488 


089 


C 


37565 


084 


c 


35876 


086 


C 


36489 


089 


C 


37600 


084 


C 


35900 


086 


C 


36490 


089 


c 


37605 


993 


C 


35901 


086 


C 


36491 


089 


C 


37606 


993 


c 


35903 


086 


c 


36493 


089 


C 


37607 


086 


c 


35905 


993 


C 


36500 


092 


c 


37609 


Oil 


C 


35907 


993 


c 


36510 


993 


C 


37615 


993 


C 


35910 


086 


c 


36520 


100 


C 


37616 


993 


C 


36000 


091 


c 


36522 


100 


C 


37617 


993 


c 


36005 


326 


c 


36530 


082 


C 


37618 


084 


C 


36010 


092 


c 


36531 


082 


c 


37620 


079 


C 


36011 


092 


c 


36532 


083 


c 


37650 


084 


c 


36012 


092 


c 


36533 


082 


c 


37660 


993 


c 


36013 


092 


c 


36534 


083 


c 


37700 


084 


c 


36014 


092 


c 


36535 


083 


c 


37720 


084 


c 


36015 


092 


c 


36600 


091 


c 


37730 


084 


c 


36100 


092 


c 


36620 


092 


c 


37735 


084 


c 


36120 


092 


c 


36625 


092 


c 


37760 


084 


c 


36140 


092 


c 


36640 


092 


c 


37780 


084 


c 


36145 


092 


c 


36660 


993 


c 


37785 


085 


c 


36160 


092 


c 


36680 


002 


c 


37788 


993 


C 


36200 


092 


c 


36800 


082 


c 


37790 


153 


C 


36215 


093 


c 


36810 


082 


c 


37799 


083 


c 


144 














Final Report 



• 



■rfff"^- 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


38100 


993 


C 


39531 


993 


C 


41017 


234 


C 


38101 


993 


C 


39540 


993 


C 


41018 


234 


C 


38102 


993 


C 


39541 


993 


C 


41100 


233 


C 


38115 


993 


C 


39545 


993 


C 


41105 


233 


C 


38200 


326 


C 


39547 


993 


c 


41108 


233 


C 


38230 


100 


C 


39599 


126 


C 


41110 


233 


C 


38231 


100 


C 


40490 


233 


C 


41112 


234 


C 


38240 


993 


C 


40500 


235 


C 


41113 


234 


C 


38241 


993 


C 


40510 


235 


C 


41114 


235 


c 


38300 


004 


C 


40520 


235 


c 


41115 


233 


C 


38305 


. 005 


C 


40525 


235 


C 


41116 


234 


C 


38308 - 


105 


C 


40527 


235 


C 


41120 


235 


C 


38380 


106 


C 


40530 


235 


c 


41130 


993 


C 


38381 


993 


C 


40650 


234 


C 


41135 


993 


C 


38382 


993 


C 


40652 


234 


C 


41140 


993 


c 


38500 


105 


C 


40654 


235 


C 


41145 


993 


C 


38505 


002 


C 


40700 


236 


c 


41150 


993 


c 


38510 


105 


C 


40701 


236 


C 


41153 


993 


C 


38520 


105 


C 


40702 


236 


c 


41155 


993 


c 


38525 


105 


C 


40720 


236 


C 


41250 


233 


C 


38530 


106 


C 


40761 


236 


C 


41251 


233 


C 


38542 


106 


C 


40799 


233 


C 


41252 


233 


C 


38550 


106 


C 


40800 


233 


C 


41500 


233 


C 


38555 


106 


c 


40801 


233 


c 


"41510 


233 


C 


38562 


106 


c 


40804 


233 


C 


41520 


233 


c 


38564 


993 


c 


40805 


233 


C 


41599 


233 


C 


38700 


993 


c 


40806 


233 


c 


41800 


233 


C 


38720 


993 


c 


40808 


233 


c 


41805 


233 


C 


38724 


993 


c 


40810 


233 


C 


41806 


233 


C 


38740 


106 


c 


40812 


233 


c 


41820 


233 


C 


38745 


106 


c 


40814 


233 


c 


41821 


233 


C 


38746 


993 


c 


40816 


234 


C 


41822 


233 


C 


38747 


993 


c 


40818 


233 


C 


41823 


233 


C 


38760 


106 


c 


40819 


233 


C 


41825 


233 


C 


38765 


993 


c 


40820 


233 


c 


41826 


234 


c 


38770 


993 


c 


40830 


233 


c 


41827 


233 


c 


38780 


993 


c 


40831 


233 


c 


41828 


233 


c 


38790 


326 


c 


40840 


235 


C 


41830 


233 


C 


38794 


092 


c 


40842 


235 


c 


41850 


233 


C 


38999 


105 


c 


40843 


236 


c 


41870 


233 


C 


39000 


993 


c 


40844 


236 


C 


41872 


233 


c 


39010 


993 


c 


40845 


236 


c 


41874 


234 


C 


39020 


993 


c 


40899 


233 


c 


41899 


233 


C 


39200 


993 


c 


41000 


233 


c 


42000 


233 


c 


39220 


993 


c 


41005 


233 


c 


42100 


233 


C 


39400 


126 


c 


41006 


233 


c 


42104 


233 


c 


39499 


126 


c 


41007 


233 


c 


42106 


233 


c 


39501 


993 


c 


41008 


233 


c 


42107 


235 


c 


39502 


993 


c 


41009 


233 


c 


42120 


235 


c 


39503 


993 


c 


41010 


233 


c 


42140 


233 


C 


39520 


993 


c 


41015 


233 


c 


42145 


235 


C 


39530 


993 


c 


41016 


234 


c 


42160 


233 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



145 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


42180 


233 


C 


42804 


233 


C 


43118 


993 


C 


42182 


235 


C 


42806 


233 


C 


43119 


993 


C 


42200 


235 


C 


42808 


234 


C 


43120 


993 


C 


42205 


235 


C 


42809 


233 


C 


43121 


993 


C 


42210 


235 


C 


42810 


234 


c 


43122 


993 


C 


42215 


235 


C 


42815 


235 


c 


43123 


993 


C 


42220 


235 


C 


42820 


237 


C 


43124 


993 


C 


42225 


235 


C 


42821 


237 


c 


43130 


993 


C 


42226 


235 


C 


42825 


237 


c 


43135 


993 


C 


42227 


235 


C 


42826 


237 


C 


43136 


234 


C 


42235 


235 


C 


42830 


237 


c 


43200 


116 


c 


42260 - 


233 


C 


42831 


237 


C 


43202 


116 


C 


42280 


233 


C 


42835 


237 


c 


43204 


117 


C 


42281 


233 


C 


42836 


237 


C 


43205 


117 


c 


42299 


233 


C 


42842 


235 


C 


43215 


116 


c 


42300 


233 


C 


42844 


993 


C 


43216 


116 


c 


42305 


234 


C 


42845 


993 


c 


43217 


116 


C 


42310 


233 


C 


42860 


237 


c 


43219 


116 


C 


42320 


233 


C 


42870 


237 


C 


43220 


116 


c 


42325 


233 


c 


42880 


235 


c 


43226 


116 


C 


42326 


233 


c 


42890 


236 


C 


43227 


117 


c 


42330 


233 


c 


42892 


236 


c 


43228 


117 


c 


42335 


234 


c 


42894 


993 


C 


43234 


116 


c 


42340 


234 


c 


42900 


233 


C 


43235 


116 


C 


42400 


002 


c 


42950 


235 


c 


43239 


116 


C 


42405 


234 


c 


42953 


235 


c 


43241 


116 


c 


42408 


234 


c 


42955 


235 


C 


43243 


117 


c 


42409 


234 


c 


42960 


232 


C 


43244 


117 


c 


42410 


235 


c 


42961 


993 


C 


43245 


117 


C 


42415 


236 


c 


42962 


235 


c 


43246 


117 


c 


42420 


236 


c 


42970 


232 


C 


43247 


117 


C 


42425 


236 


c 


42971 


993 


c 


43248 


117 


C 


42426 


993 


c 


42972 


234 


c 


43249 


117 


c 


42440 


235 


c 


42999 


233 


C 


43250 


117 


C 


42450 


234 


c 


43000 


235 


C 


43251 


117 


c 


42500 


235 


c 


43020 


235 


C 


43255 


117 


C 


42505 


235 


c 


43030 


235 


c 


43258 


117 


C 


42507 


235 


c 


43040 


235 


c 


43259 


117 


C 


42508 


235 


c 


43045 


993 


c 


43260 


124 


c 


42509 


235 


c 


43100 


126 


C 


43261 


124 


C 


42510 


235 


c 


43101 


993 


c 


43262 


124 


c 


42550 


326 


c 


43105 


993 


c 


43263 


124 


c 


42600 


234 


c 


43106 


993 


C 


43264 


124 


c 


42650 


233 


c 


43107 


993 


C 


43265 


124 


c 


42660 


233 


c 


43108 


993 


C 


43267 


124 


c 


42665 


233 


c 


43110 


993 


C 


43268 


124 


c 


42699 


233 


c 


43111 


993 


c 


43269 


124 


C 


42700 


233 


c 


43112 


993 


c 


43271 


124 


c 


42720 


233 


c 


43113 


993 


c 


43272 


124 


c 


42725 


235 


c 


43115 


993 


c 


43300 


126 


C 


42800 


233 


c 


43116 


993 


c 


43305 


126 


c 


42802 


233 


c 


43117 


993 


c 


43310 


993 


c 


146 














Final 


Report 



,.'Hr.1> 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


43312 


993 


C 


43641 


993 


C 


44151 


993 


C 


43320 


993 


C 


43750 


117 


C 


44152 


993 


C 


43321 


993 


c 


43760 


325 


c 


44153 


993 


C 


43324 


993 


c 


43761 


325 


C 


44155 


993 


C 


43325 


993 


c 


43800 


993 


C 


44156 


993 


C 


43326 


993 


c 


43810 


993 


C 


44160 


993 


C 


43330 


993 


c 


43820 


993 


c 


44300 


993 


C 


43331 


993 


c 


43825 


993 


C 


44310 


993 


C 


43340 


993 


c 


43830 


126 


c 


44312 


126 


C 


43341 


993 


c 


43831 


993 


C 


44314 


993 


C 


43350 


993 


c 


43832 


993 


C 


44316 


993 


C 


43351 ■ 


993 


c 


43840 


993 


c 


44320 


993 


C 


43352 


993 


c 


43842 


993 


c 


44322 


993 


C 


43360 


993 


c 


43843 


993 


c 


44340 


126 


C 


43361 


993 


c 


43844 


993 


C 


44345 


993 


C 


43400 


993 


c 


43846 


993 


C 


44346 


993 


C 


43401 


993 


c 


43847 


993 


c 


44360 


116 


C 


43405 


993 


c 


43848 


993 


C 


44361 


116 


C 


43410 


126 


c 


43850 


993 


c 


44363 


117 


C 


43415 


993 


c 


43855 


993 


C 


44364 


117 


C 


43420 


993 


c 


43860 


993 


C 


44365 


117 


C 


43425 


993 


c 


43865 


993 


C 


44366 


117 


C 


43450 


118 


c 


43870 


126 


C 


44369 


117 


C 


43451 


118 


c 


43880 


993 


C 


44372 


117 


C 


43453 


118 


c 


43885 


993 


C 


44373 


117 


C 


43455 


118 


c 


43999 


126 


c 


44376 


117 


c 


43456 


118 


c 


44005 


126 


c 


44377 


117 


C 


43458 


118 


c 


44010 


993 


c 


44378 


117 


C 


43460 


993 


c 


44015 


126 


c 


44380 


119 


C 


43499 


126 


c 


44020 


993 


C 


44382 


119 


C 


43500 


993 


c 


44021 


993 


C 


44385 


119 


C 


43501 


993 


c 


44025 


993 


C 


44386 


119 


C 


43502 


993 


c 


44040 


993 


c 


44388 


119 


C 


43510 


993 


c 


44050 


993 


c 


44389 


119 


c 


43520 


993 


c 


44055 


993 


c 


44390 


119 


c 


43600 


116 


c 


44100 


116 


c 


44391 


119 


C 


43605 


993 


c 


44110 


993 


c 


44392 


119 


C 


43610 


993 


c 


44111 


993 


c 


44393 


119 


C 


43611 


993 


c 


44120 


993 


c 


44394 


119 


c 


43620 


993 


c 


44121 


993 


C 


44500 


325 


C 


43621 


993 


c 


44125 


993 


C 


44600 


993 


c 


43622 


993 


c 


44130 


993 


C 


44602 


993 


c 


43625 


993 


c 


44131 


993 


c 


44603 


993 


c 


43630 


993 


c 


44139 


993 


c 


44604 


993 


C 


43631 


993 


c 


44140 


993 


c 


44605 


993 


C 


43632 


993 


c 


44141 


993 


c 


44610 


993 


c 


43633 


993 


c 


44143 


993 


c 


44615 


993 


c 


43634 


993 


c 


44144 


993 


c 


44620 


126 


c 


43635 


993 


c 


44145 


993 


c 


44625 


993 


c 


43638 


993 


c 


44146 


993 


c 


44640 


126 


c 


43639 


993 


c 


44147 


993 


c 


44650 


993 


C 


43640 


993 


c 


44150 


993 


c 


44660 


993 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



147 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


44661 


993 


C 


45339 


121 


C 


46281 


128 


C 


44680 


993 


C 


45355 


119 


C 


46285 


127 


C 


44799 


126 


C 


45378 


119 


C 


46288 


128 


C 


44800 


993 


C 


45379 


120 


C 


46320 


127 


C 


44820 


993 


C 


45380 


119 


C 


46500 


085 


C 


44850 


993 


C 


45382 


120 


C 


46600 


122 


C 


44899 


993 


C 


45383 


120 


c 


46602 


122 


C 


44900 


993 


C 


45384 


120 


c 


46604 


122 


C 


44950 


126 


C 


45385 


120 


C 


46606 


123 


C 


44955 


993 


C 


45500 


128 


c 


46608 


123 


C 


44960 


- 993 


C 


45505 


128 


c 


46610 


123 


C 


45000 - 


005 


C 


45520 


326 


c 


46611 


123 


C 


45005 


127 


C 


45540 


993 


c 


46612 


123 


C 


45020 


005 


C 


45541 


993 


C 


46614 


123 


C 


45100 


127 


C 


45550 


993 


C 


46615 


123 


C 


45108 


128 


C 


45560 


993 


c 


46700 


128 


C 


45110 


993 


C 


45562 


128 


C 


46705 


128 


C 


45111 


993 


C 


45563 


993 


c 


46715 


128 


C 


45112 


993 


C 


45800 


128 


c 


46716 


128 


C 


45113 


128 


C 


45805 


993 


c 


46730 


993 


C 


45114 


993 


C 


45820 


128 


C 


46735 


993 


C 


45116 


993 


c 


45825 


993 


c 


46740 


128 


C 


45120 


993 


c 


45900 


127 


c 


46742 


993 


C 


45121 


993 


c 


45905 


127 


c 


46744 


993 


C 


45123 


128 


c 


45910 


127 


C 


46746 


993 


c 


45130 


993 


c 


45915 


127 


C 


46748 


993 


C 


45135 


993 


c 


45999 


127 


C 


46750 


128 


C 


45150 


128 


c 


46000 


127 


C 


46751 


128 


c 


45160 


128 


c 


46030 


127 


c 


46753 


128 


C 


45170 


128 


c 


46040 


005 


c 


46754 


127 


c 


45180 


128 


c 


46045 


005 


c 


46760 


128 


c 


45190 


128 


c 


46050 


004 


c 


46761 


128 


C 


45300 


123 


c 


46060 


128 


c 


46762 


128 


c 


45302 


123 


c 


46070 


127 


C 


46900 


008 


C 


45303 


123 


c 


46080 


127 


c 


46910 


008 


C 


45305 


121 


c 


46083 


127 


c 


46916 


008 


C 


45307 


121 


c 


46200 


127 


c 


46917 


009 


C 


45308 


121 


c 


46210 


127 


C 


46922 


009 


C 


45309 


121 


c 


46211 


127 


c 


46924 


009 


C 


45310 


121 


c 


46220 


123 


c 


46934 


127 


c 


45315 


121 


c 


46221 


127 


c 


46935 


127 


C 


45317 


121 


c 


46230 


127 


c 


46936 


127 


C 


45320 


121 


c 


46250 


127 


C 


46937 


127 


C 


45321 


121 


c 


46255 


128 


c 


46938 


127 


C 


45330 


123 


c 


46257 


128 


c 


46940 


127 


C 


45331 


121 


c 


46258 


128 


c 


46942 


127 


C 


45332 


121 


c 


46260 


128 


c 


46945 


127 


C 


45333 


121 


c 


46261 


128 


c 


46946 


127 


C 


45334 


121 


c 


46262 


128 


c 


46999 


127 


C 


45336 


121 


c 


46270 


127 


c 


47000 


003 


c 


45337 


121 


c 


46275 


128 


C 


47001 


003 


C 


45338 


121 


c 


46280 


128 


c 


47010 


993 


C 


148 














Final 


Report 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


47015 


993 


C 


47741 


993 


C 


49215 


993 


C 


47100 


993 


C 


47760 


993 


C 


49220 


993 


C 


47120 


993 


C 


47765 


993 


c 


49250 


126 


C 


47122 


993 


C 


47780 


993 


C 


49255 


993 


C 


47125 


993 


C 


47785 


993 


C 


49300 


129 


C 


47130 


993 


C 


47800 


993 


C 


49301 


129 


C 


47133 


993 


C 


47801 


126 


C 


49302 


124 


C 


47134 


993 


C 


47802 


993 


C 


49303 


124 


C 


47135 


993 


C 


47900 


993 


C 


49310 


130 


C 


47136 


993 


C 


47999 


126 


C 


49311 


130 


C 


47300 


. 993 


C 


48000 


993 


C 


49315 


129 


C 


47350 - 


993 


C 


48001 


993 


C 


49400 


058 


C 


47355 


993 


C 


48005 


993 


C 


49401 


058 


C 


47360 


993 


C 


48020 


993 


C 


49420 


003 


C 


47361 


993 


C 


48100 


993 


C 


49421 


126 


C 


47362 


993 


c 


48102 


003 


C 


49422 


993 


C 


47399 


126 


c 


48120 


993 


c 


49425 


993 


C 


47400 


993 


c 


48140 


993 


c 


49426 


126 


C 


47420 


993 


c 


48145 


993 


c 


49427 


326 


c 


47425 


993 


c 


48146 


993 


c 


49428 


993 


C 


47440 


993 


c 


48148 


993 


c 


49429 


083 


C 


47460 


993 


c 


48150 


993 


c 


49495 


125 


C 


47480 


993 


c 


48151 


993 


c 


49496 


125 


c 


47490 


126 


c 


48152 


993 


c 


49500 


125 


C 


47500 


326 


c 


48153 


993 


c 


49501 


125 


C 


47505 


326 


c 


48154 


993 


c 


49505 


125 


C 


47510 


124 


c 


48155 


993 


c 


49507 


125 


c 


47511 


124 


c 


48160 


993 


c 


49510 


125 


c 


47525 


126 


c 


48180 


993 


c 


49515 


125 


c 


47530 


126 


c 


48400 


993 


c 


49520 


125 


c 


47550 


993 


c 


48500 


993 


c 


49521 


125 


C 


47552 


124 


c 


48510 


993 


c 


49525 


125 


C 


47553 


124 


c 


48520 


993 


c 


49530 


125 


C 


47554 


124 


c 


48540 


993 


c 


49535 


125 


C 


47555 


124 


c 


48545 


993 


c 


49540 


125 


C 


47556 


124 


c 


48547 


993 


c 


49550 


125 


c 


47600 


126 


c 


48550 


993 


c 


49552 


125 


C 


47605 


126 


c 


48554 


993 


c 


49553 


125 


C 


47610 


993 


c 


48556 


993 


c 


49555 


125 


C 


47612 


993 


c 


48999 


126 


c 


49557 


125 


C 


47620 


993 


c 


49000 


993 


c 


49560 


125 


C 


47630 


124 


c 


49002 


993 


c 


49561 


125 


C 


47700 


993 


c 


49010 


993 


c 


49565 


125 


C 


47701 


993 


c 


49020 


993 


c 


49566 


125 


c 


47710 


993 


c 


49040 


993 


c 


49568 


125 


C 


47711 


993 


c 


49060 


993 


c 


49570 


125 


c 


47712 


993 


c 


49080 


058 


c 


49572 


125 


c 


47715 


993 


c 


49081 


058 


c 


49575 


125 


C 


47716 


993 


c 


49085 


126 


c 


49580 


126 


C 


47720 


993 


c 


49180 


003 


c 


49581 


126 


C 


47721 


993 


c 


49200 


126 


c 


49582 


126 


C 


47740 


993 


c 


49201 


126 


c 


49585 


126 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



149 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


49587 


126 


C 


50520 


993 


C 


50900 


993 


C 


49590 


125 


C 


50525 


993 


C 


50920 


993 


C 


49600 


126 


C 


50526 


993 


C 


50930 


993 


C 


49605 


993 


C 


50540 


993 


C 


50940 


993 


C 


49606 


126 


C 


50551 


135 


C 


50951 


135 


c 


49610 


126 


C 


50553 


135 


C 


50953 


135 


C 


49611 


993 


C 


50555 


135 


C 


50955 


135 


C 


49900 


993 


C 


50557 


135 


C 


50957 


135 


C 


49905 


993 


C 


50559 


135 


C 


50959 


135 


C 


49999 


126 


C 


50561 


135 


C 


50961 


135 


c 


50010 


993 


C 


50570 


993 


c 


50970 


993 


C 


50020 - 


993 


C 


50572 


993 


C 


50972 


993 


C 


50040 


993 


C 


50574 


993 


C 


50974 


993 


c 


50045 


993 


C 


50575 


993 


C 


50976 


993 


C 


50060 


993 


C 


50576 


993 


C 


50978 


993 


C 


50065 


993 


c 


50578 


993 


c 


50980 


993 


c 


50070 


993 


c 


50580 


993 


C 


51000 


133 


C 


50075 


993 


c 


50590 


131 


C 


51005 


133 


C 


50080 


136 


c 


50600 


993 


C 


51010 


133 


C 


50081 


136 


c 


50605 


993 


C 


51020 


136 


C 


50100 


993 


c 


50610 


993 


C 


51030 


136 


C 


50120 


993 


c 


50620 


993 


C 


51040 


135 


C 


50125 


993 


c 


50630 


993 


C 


51045 


136 


C 


50130 


993 


c 


50650 


993 


C 


51050 


136 


C 


50135 


993 


c 


50660 


993 


C 


51060 


136 


C 


50200 


003 


c 


50684 


326 


C 


51065 


136 


C 


50205 


993 


c 


50686 


132 


M 


51080 


126 


C 


50220 


993 


c 


50688 


325 


C 


51500 


126 


C 


50225 


993 


c 


50690 


326 


C 


51520 


136 


C 


50230 


993 


c 


50700 


993 


C 


51525 


993 


C 


50234 


993 


c 


50715 


993 


C 


51530 


993 


C 


50236 


993 


c 


50722 


993 


C 


51535 


993 


C 


50240 


993 


c 


50725 


993 


C 


51550 


993 


C 


50280 


993 


c 


50727 


126 


C 


51555 


993 


C 


50290 


993 


c 


50728 


126 


C 


51565 


993 


C 


50300 


993 


c 


50740 


993 


C 


51570 


993 


C 


50320 


993 


c 


50750 


993 


C 


51575 


993 


C 


50340 


993 


c 


50760 


993 


C 


51580 


993 


C 


50360 


993 


c 


50770 


993 


C 


51585 


993 


C 


50365 


993 


c 


50780 


993 


C 


51590 


993 


C 


50370 


993 


c 


50782 


993 


C 


51595 


993 


C 


50380 


993 


c 


50783 


993 


C 


51596 


993 


C 


50390 


003 


c 


50785 


993 


C 


51597 


993 


C 


50392 


126 


c 


50800 


993 


C 


51600 


326 


C 


50393 


126 


c 


50810 


993 


C 


51605 


326 


C 


50394 


326 


c 


50815 


993 


c 


51610 


326 


C 


50395 


126 


c 


50820 


993 


c 


51700 


133 


C 


50396 


132 


M 


50825 


993 


c 


51705 


325 


C 


50398 


325 


c 


50830 


993 


c 


51710 


325 


C 


50400 


993 


c 


50840 


993 


c 


51715 


135 


C 


50405 


993 


c 


50845 


126 


c 


51720 


098 


C 


50500 


993 


c 


50860 


993 


c 


51725 


132 


M 


150 














Final 


Report 



«f^1f**.- 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


51726 


132 


M 


52325 


136 


C 


53440 


153 


C 


51736 


137 


M 


52327 


135 


C 


53442 


136 


C 


51739 


137 


M 


52330 


135 


c 


53443 


136 


C 


51741 


137 


M 


52332 


135 


C 


53445 


151 


C 


51772 


132 


M 


52334 


135 


C 


53447 


136 


C 


51784 


191 


M 


52335 


136 


C 


53449 


136 


C 


51785 


191 


M 


52336 


136 


C 


53450 


136 


C 


51792 


132 


M 


52337 


136 


C 


53460 


135 


C 


51795 


132 


M 


52338 


136 


C 


53502 


135 


C 


51797 


132 


M 


52339 


136 


C 


53505 


135 


C 


51800 


. 993 


C 


52340 


136 


C 


53510 


136 


C 


51820 - 


993 


C 


52450 


136 


C 


53515 


136 


c 


51840 


136 


C 


52500 


136 


C 


53520 


136 


C 


51841 


136 


C 


52510 


136 


C 


53600 


133 


C 


51845 


136 


C 


52601 


136 


c 


53601 


133 


C 


51860 


993 


C 


52606 


136 


C 


53605 


133 


C 


51865 


993 


C 


52612 


993 


C 


53620 


133 


C 


51880 


136 


C 


52614 


993 


c 


53621 


133 


C 


51900 


993 


C 


52620 


136 


C 


53640 


133 


C 


51920 


993 


C 


52630 


136 


C 


53660 


133 


C 


51925 


993 


c 


52640 


136 


C 


53661 


133 


C 


51940 


993 


c 


52647 


136 


C 


53665 


133 


c 


51960 


993 


c 


52648 


136 


C 


53670 


133 


C 


51980 


993 


c 


52650 


993 


C 


53675 


133 


C 


52000 


134 


c 


52700 


135 


C 


53800 


373 


C 


52005 


134 


c 


53000 


134 


C 


53899 


134 


C 


52007 


135 


c 


53010 


134 


C 


54000 


152 


C 


52010 


135 


c 


53020 


134 


C 


54001 


152 


C 


52204 


134 


c 


53025 


134 


c 


54015 


005 


c 


52214 


135 


c 


53040 


134 


c 


54050 


008 


C 


52224 


135 


c 


53060 


134 


C 


54055 


008 


C 


52234 


135 


c 


53080 


135 


c 


54056 


008 


c 


52235 


136 


c 


53085 


136 


c 


54057 


009 


c 


52240 


136 


c 


53200 


134 


C 


54060 


009 


C 


52250 


135 


c 


53210 


136 


C 


54065 


009 


C 


52260 


135 


c 


53215 


136 


c 


54100 


010 


c 


52265 


134 


c 


53220 


135 


C 


54105 


Oil 


c 


52270 


135 


c 


53230 


136 


C 


54110 


153 


c 


52275 


135 


c 


53235 


136 


C 


54111 


153 


c 


52276 


135 


c 


53240 


135 


c 


54112 


153 


C 


52277 


136 


c 


53250 


135 


c 


54115 


152 


C 


52281 


134 


c 


53260 


134 


c 


54120 


136 


C 


52283 


134 


c 


53265 


134 


C 


54125 


993 


c 


52285 


135 


c 


53270 


134 


C 


54130 


993 


c 


52290 


135 


c 


53275 


134 


c 


54135 


993 


C 


52300 


135 


c 


53400 


136 


C 


54150 


152 


c 


52305 


135 


c 


53405 


136 


C 


54152 


152 


c 


52310 


135 


c 


53410 


136 


c 


54160 


152 


c 


52315 


135 


c 


53415 


136 


C 


54161 


152 


c 


52317 


136 


c 


53420 


136 


c 


54200 


326 


c 


52318 


136 


c 


53425 


136 


c 


54205 


153 


c 


52320 


136 


c 


53430 


136 


c 


54220 


152 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



151 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


54230 


326 


C 


54700 


005 


C 


55970 


993 


C 


54231 


152 


C 


54800 


003 


C 


55980 


993 


C 


54235 


326 


c 


54820 


150 


C 


56300 


129 


C 


54240 


132 


M 


54830 


150 


C 


56301 


129 


C 


54250 


132 


M 


54840 


150 


C 


56302 


129 


C 


54300 


153 


C 


54860 


150 


c 


56303 


129 


C 


54304 


153 


C 


54861 


150 


C 


56304 


129 


C 


54308 


153 


c 


54900 


150 


C 


56305 


129 


C 


54312 


153 


c 


54901 


150 


C 


56306 


129 


C 


54316 


153 


c 


55000 


002 


C 


56307 


130 


c 


54318 


. 153 


c 


55040 


150 


C 


56308 


130 


c 


54322 - 


153 


c 


55041 


150 


C 


56309 


129 


c 


54324 


153 


c 


55060 


150 


C 


56311 


130 


c 


54326 


153 


c 


55100 


004 


C 


56312 


130 


c 


54328 


153 


c 


55110 


150 


C 


56313 


130 


c 


54332 


153 


c 


55120 


150 


C 


56315 


129 


c 


54336 


153 


c 


55150 


150 


C 


56316 


129 


c 


54340 


153 


c 


55175 


150 


c 


56317 


125 


c 


54344 


153 


c 


55180 


150 


c 


56320 


129 


c 


54348 


153 


c 


55200 


154 


c 


56322 


130 


c 


54352 


153 


c 


55250 


154 


c 


56323 


130 


c 


54360 


153 


c 


55300 


154 


c 


56324 


130 


c 


54380 


153 


c 


55400 


154 


c 


56340 


130 


c 


54385 


153 


c 


55450 


154 


c 


56341 


130 


c 


54390 


153 


c 


55500 


150 


c 


56342 


130 


c 


54400 


151 


c 


55520 


150 


c 


56343 


129 


c 


54401 


151 


c 


55530 


150 


c 


56344 


129 


c 


54402 


153 


c 


55535 


150 


c 


56350 


170 


c 


54405 


151 


c 


55540 


150 


c 


56351 


170 


c 


54407 


153 


c 


55600 


135 


c 


56352 


170 


c 


54409 


153 


c 


55605 


135 


c 


56353 


170 


c 


54420 


153 


c 


55650 


150 


c 


56354 


170 


c 


54430 


153 


c 


55680 


135 


c 


56355 


170 


c 


54435 


152 


c 


55700 


155 


c 


56356 


170 


c 


54440 


153 


c 


55705 


155 


c 


56360 


129 


c 


54450 


152 


c 


55720 


136 


c 


56361 


129 


c 


54500 


002 


c 


55725 


136 


c 


56362 


129 


c 


54505 


150 


c 


55801 


993 


c 


56363 


129 


c 


54510 


150 


c 


55810 


993 


c 


56399 


129 


c 


54520 


150 


c 


55812 


993 


c 


56405 


166 


c 


54530 


993 


c 


55815 


993 


c 


56420 


166 


c 


54535 


993 


c 


55821 


993 


c 


56440 


167 


c 


54550 


150 


c 


55831 


993 


c 


56441 


166 


c 


54560 


993 


c 


55840 


993 


c 


56501 


166 


c 


54600 


150 


c 


55842 


993 


c 


56515 


167 


c 


54620 


150 


c 


55845 


993 


c 


56605 


166 


c 


54640 


150 


c 


55859 


326 


c 


56606 


166 


c 


54645 


150 


c 


55860 


136 


c 


56620 


168 


c 


54650 


993 


c 


55862 


993 


c 


56625 


168 


c 


54660 


150 


c 


55865 


993 


c 


56630 


993 


c 


54670 


150 


c 


55870 


161 


c 


56631 


993 


c 


54680 


150 


c 


55899 


134 


c 


56632 


993 


c 


152 














Final 


Report 



-vtr.^^i. 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


56633 


993 


C 


57410 


166 


C 


58520 


993 


C 


56634 


993 


C 


57415 


166 


C 


58540 


993 


C 


56637 


993 


C 


57452 


166 


C 


58600 


168 


C 


56640 


993 


C 


57454 


166 


c 


58605 


993 


C 


56700 


166 


C 


57460 


167 


c 


58611 


993 


c 


56720 


166 


C 


57500 


166 


c 


58615 


168 


c 


56740 


167 


C 


57505 


166 


c 


58700 


993 


c 


56800 


167 


C 


57510 


166 


c 


58720 


993 


c 


56805 


993 


C 


57511 


166 


c 


58740 


168 


c 


56810 


167 


C 


57513 


166 


c 


58750 


993 


c 


57000 


- 167 


C 


57520 


167 


c 


58752 


993 


c 


57010 - 


167 


C 


57522 


167 


c 


58760 


993 


c 


57020 


166 


C 


57530 


168 


c 


58770 


993 


c 


57061 


166 


C 


57540 


993 


c 


58800 


167 


c 


57065 


167 


C 


57545 


993 


c 


58805 


993 


c 


57100 


166 


C 


57550 


168 


c 


58820 


167 


c 


57105 


166 


C 


57555 


168 


c 


58822 


993 


c 


57108 


168 


C 


57556 


168 


c 


58825 


993 


c 


57110 


993 


C 


57700 


167 


c 


58900 


993 


c 


57120 


168 


C 


57720 


167 


c 


58920 


993 


c 


57130 


167 


C 


57800 


166 


c 


58925 


168 


c 


57135 


167 


c 


57820 


169 


c 


58940 


993 


c 


57150 


171 


c 


58100 


171 


c 


58943 


993 


c 


57160 


171 


c 


58120 


169 


c 


58950 


993 


c 


57170 


171 


c 


58140 


993 


c 


58951 


993 


c 


57180 


166 


c 


58145 


168 


c 


58952 


993 


c 


57200 


167 


c 


58150 


993 


c 


58960 


993 


c 


57210 


167 


c 


58152 


993 


c 


58970 


161 


c 


57220 


135 


c 


58180 


993 


c 


58972 


352 


M 


57230 


167 


c 


58200 


993 


c 


58974 


161 


c 


57240 


168 


c 


58210 


993 


c 


58976 


161 


c 


57250 


168 


c 


58240 


993 


c 


58999 


166 


c 


57260 


168 


c 


58260 


993 


c 


59000 


171 


c 


57265 


168 


c 


58262 


993 


c 


59012 


993 


c 


57268 


168 


c 


58263 


993 


c 


59015 


171 


c 


57270 


993 


c 


58267 


993 


c 


59020 


162 


M 


57280 


993 


c 


58270 


993 


c 


59025 


162 


M 


57282 


168 


c 


58275 


993 


c 


59030 


162 


M 


57284 


168 


c 


58280 


993 


c 


59050 


162 


M 


57288 


168 


c 


58285 


993 


c 


59051 


162 


P 


57289 


168 


c 


58300 


171 


c 


59100 


993 


C 


57291 


168 


c 


58301 


171 


c 


59120 


993 


c 


57292 


993 


c 


58310 


161 


c 


59121 


993 


c 


57300 


168 


c 


58311 


161 


c 


59130 


993 


c 


57305 


993 


c 


58321 


161 


c 


59135 


993 


c 


57307 


993 


c 


58322 


161 


c 


59136 


993 


c 


57310 


993 


c 


58323 


354 


c 


59140 


993 


c 


57311 


993 


c 


58340 


326 


c 


59150 


993 


c 


57320 


993 


c 


58345 


167 


c 


59151 


993 


c 


57330 


993 


c 


58350 


166 


c 


59160 


169 


c 


57335 


993 


c 


58400 


993 


c 


59200 


171 


c 


57400 


166 


c 


58410 


168 


c 


59300 


166 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



153 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


59320 


167 


C 


60281 


106 


C 


61458 


993 


C 


59325 


167 


C 


60500 


236 


C 


61460 


993 


C 


59350 


993 


c 


60502 


993 


C 


61470 


993 


C 


59400 


995 


c 


60505 


993 


C 


61480 


993 


C 


59409 


165 


c 


60512 


993 


C 


61490 


993 


C 


59410 


165 


c 


60520 


993 


C 


61500 


993 


C 


59412 


165 


c 


60521 


993 


C 


61501 


993 


C 


59414 


993 


c 


60522 


993 


C 


61510 


993 


C 


59425 


422 


c 


60540 


993 


C 


61512 


993 


C 


59426 


422 


c 


60545 


993 


C 


61514 


993 


C 


59430 


, 422 


c 


60600 


106 


C 


61516 


993 


C 


59510 - 


995 


c 


60605 


236 


C 


61518 


993 


C 


59514 


993 


c 


60699 


105 


C 


61519 


993 


C 


59515 


993 


c 


61000 


198 


C 


61520 


993 


C 


59525 


993 


c 


61001 


198 


C 


61521 


993 


c 


59610 


165 


c 


61020 


198 


C 


61522 


993 


C 


59612 


165 


c 


61026 


198 


C 


61524 


993 


C 


59614 


165 


c 


61050 


198 


C 


61526 


993 


C 


59618 


993 


c 


61055 


198 


C 


61530 


993 


C 


59620 


993 


c 


61070 


326 


C 


61531 


993 


C 


59622 


993 


c 


61105 


993 


C 


61533 


993 


C 


59812 


163 


c 


61106 


993 


c 


61534 


993 


C 


59820 


163 


c 


61107 


993 


C 


61535 


993 


C 


59821 


163 


c 


61108 


993 


C 


61536 


993 


C 


59830 


163 


c 


61120 


993 


C 


61538 


993 


C 


59840 


164 


c 


61130 


993 


C 


61539 


993 


C 


59841 


164 


c 


61140 


993 


C 


61541 


993 


C 


59850 


164 


c 


61150 


993 


c 


61542 


993 


C 


59851 


164 


c 


61151 


993 


C 


61543 


993 


C 


59852 


993 


c 


61154 


993 


C 


61544 


993 


C 


59855 


993 


c 


61156 


993 


c 


61545 


993 


C 


59856 


993 


c 


61210 


993 


C 


61546 


993 


c 


59857 


993 


c 


61215 


193 


C 


61548 


993 


C 


59870 


164 


c 


61250 


993 


C 


61550 


993 


C 


59899 


162 


M 


61253 


993 


C 


61552 


993 


C 


60000 


233 


c 


61304 


993 


C 


61556 


993 


C 


60001 


002 


c 


61305 


993 


C 


61557 


993 


C 


60100 


002 


c 


61312 


993 


C 


61558 


993 


c 


60200 


106 


c 


61313 


993 


C 


61559 


993 


C 


60210 


106 


c 


61314 


993 


c 


61563 


993 


c 


60212 


106 


c 


61315 


993 


C 


61564 


993 


C 


60220 


106 


c 


61320 


993 


C 


61570 


993 


C 


60225 


106 


c 


61321 


993 


c 


61571 


993 


C 


60240 


106 


c 


61330 


236 


C 


61575 


993 


C 


60245 


106 


c 


61332 


236 


C 


61576 


993 


C 


60246 


993 


c 


61333 


993 


c 


61580 


993 


C 


60252 


993 


c 


61334 


993 


C 


61581 


993 


C 


60254 


993 


c 


61340 


993 


C 


61582 


993 


C 


60260 


993 


c 


61343 


993 


C 


61583 


993 


C 


60270 


993 


c 


61345 


993 


c 


61584 


993 


C 


60271 


993 


c 


61440 


993 


C 


61585 


993 


C 


60280 


106 


c 


61450 


993 


c 


61590 


993 


c 


154 














Final 


Report 



■**»<• 






Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


61591 


993 


C 


61875 


993 


C 


62292 


198 


C 


61592 


993 


C 


61880 


993 


C 


62294 


198 


C 


61595 


993 


c 


61885 


193 


C 


62298 


198 


C 


61596 


993 


c 


61888 


993 


C 


62350 


195 


C 


61597 


993 


c 


62000 


993 


C 


62351 


993 


C 


61598 


993 


c 


62005 


993 


C 


62355 


195 


c 


61600 


993 


c 


62010 


993 


C 


62360 


195 


c 


61601 


993 


c 


62100 


993 


c 


62361 


195 


c 


61605 


993 


c 


62115 


993 


c 


62362 


195 


c 


61606 


993 


c 


62116 


993 


c 


62365 


195 


c 


61607 


. 993 


c 


62117 


993 


c 


62367 


340 


M 


61608 - 


993 


c 


62120 


993 


c 


62368 


340 


M 


61609 


993 


c 


62121 


993 


c 


63001 


993 


c 


61610 


993 


c 


62140 


993 


c 


63003 


993 


C 


61611 


993 


c 


62141 


993 


c 


63005 


993 


C 


61612 


993 


c 


62142 


993 


c 


63011 


993 


C 


61613 


993 


c 


62143 


993 


c 


63012 


993 


C 


61615 


993 


c 


62145 


993 


c 


63015 


993 


C 


61616 


993 


c 


62146 


993 


c 


63016 


993 


C 


61618 


993 


c 


62147 


993 


c 


63017 


993 


C 


61619 


993 


c 


62180 


993 


c 


63020 


993 


C 


61624 


079 


c 


62190 


993 


c 


63030 


993 


C 


61626 


079 


c 


62192 


993 


c 


63035 


993 


C 


61680 


993 


c 


62194 


195 


c 


63040 


993 


C 


61682 


993 


c 


62200 


993 


c 


63042 


993 


C 


61684 


993 


c 


62201 


993 


c 


63045 


993 


C 


61686 


993 


c 


62220 


993 


c 


63046 


993 


c 


61690 


993 


c 


62223 


993 


c 


63047 


993 


c 


61692 


993 


c 


62225 


195 


c 


63048 


993 


c 


61700 


993 


c 


62230 


195 


c 


63055 


993 


c 


61702 


993 


c 


62256 


993 


c 


63056 


993 


c 


61703 


993 


c 


62258 


993 


c 


63057 


993 


c 


61705 


993 


c 


62268 


198 


c 


63064 


993 


c 


61708 


993 


c 


62269 


003 


c 


63066 


993 


c 


61710 


993 


c 


62270 


199 


c 


63075 


993 


c 


61711 


993 


c 


62272 


199 


c 


63076 


993 


c 


61712 


993 


c 


62273 


198 


c 


63077 


993 


c 


61720 


993 


c 


62274 


198 


c 


63078 


993 


c 


61735 


993 


c 


62275 


198 


c 


63081 


993 


c 


61750 


993 


c 


62276 


198 


c 


63082 


993 


c 


61751 


993 


c 


62277 


198 


c 


63085 


993 


c 


61760 


993 


c 


62278 


198 


c 


63086 


993 


c 


61770 


993 


c 


62279 


198 


c 


63087 


993 


c 


61790 


192 


c 


62280 


198 


c 


63088 


993 


c 


61791 


993 


c 


62281 


198 


c 


63090 


993 


c 


61793 


248 


M 


62282 


198 


c 


63091 


993 


c 


61795 


993 


c 


62284 


200 


c 


63170 


993 


c 


61850 


993 


c 


62287 


201 


c 


63172 


993 


c 


61855 


993 


c 


62288 


198 


c 


63173 


993 


c 


61860 


993 


c 


62289 


198 


c 


63180 


993 


c 


61865 


993 


c 


62290 


200 


c 


63182 


993 


c 


61870 


993 


c 


62291 


200 


c 


63185 


993 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



155 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


63190 


993 


C 


63691 


340 


M 


64600 


201 


C 


63191 


993 


C 


63700 


993 


C 


64605 


201 


C 


63194 


993 


C 


63702 


993 


C 


64610 


197 


C 


63195 


993 


C 


63704 


993 


C 


64612 


201 


C 


63196 


993 


C 


63706 


993 


C 


64613 


201 


c 


63197 


993 


C 


63707 


993 


C 


64620 


201 


C 


63198 


993 


C 


63709 


993 


C 


64622 


201 


c 


63199 


993 


C 


63710 


993 


c 


64623 


201 


C 


63200 


993 


C 


63740 


993 


c 


64630 


201 


C 


63250 


993 


c 


63741 


993 


c 


64640 


201 


c 


63251 


- 993 


c 


63744 


195 


c 


64680 


201 


c 


63252 - 


993 


c 


63746 


195 


c 


64702 


197 


C 


63265 


993 


c 


63750 


993 


c 


64704 


197 


C 


63266 


993 


c 


63780 


195 


c 


64708 


197 


C 


63267 


993 


c 


64400 


201 


c 


64712 


196 


c 


63268 


993 


c 


64402 


201 


c 


64713 


993 


C 


63270 


993 


c 


64405 


201 


c 


64714 


196 


C 


63271 


993 


c 


64408 


201 


c 


64716 


197 


C 


63272 


993 


c 


64410 


201 


c 


64718 


197 


C 


63273 


993 


c 


64412 


201 


c 


64719 


197 


c 


63275 


993 


c 


64413 


201 


c 


64721 


197 


c 


63276 


993 


c 


64415 


201 


c 


64722 


197 


c 


63277 


993 


c 


64417 


201 


c 


64726 


197 


C 


63278 


993 


c 


64418 


201 


c 


64727 


197 


C 


63280 


993 


c 


64420 


201 


c 


64732 


197 


C 


63281 


993 


c 


64421 


201 


c 


64734 


197 


C 


63282 


993 


c 


64425 


201 


c 


64736 


197 


C 


63283 


993 


c 


64430 


201 


c 


64738 


197 


C 


63285 


993 


c 


64435 


201 


c 


64740 


197 


C 


63286 


993 


c 


64440 


201 


c 


64742 


197 


C 


63287 


993 


c 


64441 


201 


c 


64744 


197 


C 


63290 


993 


c 


64442 


201 


c 


64746 


197 


C 


63300 


993 


c 


64443 


201 


c 


64752 


993 


C 


63301 


993 


c 


64445 


201 


c 


64755 


993 


C 


63302 


993 


c 


64450 


201 


c 


64760 


993 


C 


63303 


993 


c 


64505 


201 


c 


64761 


197 


C 


63304 


993 


c 


64508 


201 


c 


64763 


993 


C 


63305 


993 


c 


64510 


201 


c 


64766 


993 


c 


63306 


993 


c 


64520 


201 


c 


64771 


197 


C 


63307 


993 


c 


64530 


201 


c 


64772 


197 


C 


63308 


993 


c 


64550 


317 


c 


64774 


197 


C 


63600 


192 


c 


64553 


194 


c 


64776 


197 


C 


63610 


192 


c 


64555 


194 


c 


64778 


197 


C 


63615 


192 


c 


64560 


194 


c 


64782 


197 


C 


63650 


192 


c 


64565 


194 


c 


64783 


197 


C 


63655 


993 


c 


64573 


194 


c 


64784 


196 


c 


63657 


993 


c 


64575 


194 


c 


64786 


196 


c 


63658 


993 


c 


64577 


194 


c 


64787 


197 


c 


63660 


195 


c 


64580 


194 


c 


64788 


197 


c 


63685 


193 


c 


64585 


195 


c 


64790 


196 


C 


63688 


195 


c 


64590 


193 


c 


64792 


196 


C 


63690 


340 


M 


64595 


195 


c 


64795 


197 


C 


156 














Final 


Report 



'1! I' 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


64802 


993 


C 


65135 


223 


C 


65900 


215 


C 


64804 


993 


C 


65140 


223 


C 


65920 


215 


C 


64809 


993 


C 


65150 


223 


C 


65930 


215 


C 


64818 


993 


c 


65155 


223 


C 


66020 


221 


C 


64820 


993 


c 


65175 


223 


C 


66030 


221 


C 


64830 


197 


c 


65205 


205 


C 


66130 


215 


C 


64831 


197 


c 


65210 


205 


C 


66150 


215 


C 


64832 


197 


c 


65220 


205 


C 


66155 


216 


C 


64834 


197 


c 


65222 


205 


C 


66160 


216 


C 


64835 


196 


c 


65235 


215 


C 


66165 


216 


C 


64836 


- 196 


c 


65260 


218 


C 


66170 


216 


C 


64837 - 


197 


c 


65265 


218 


C 


66172 


216 


C 


64840 


196 


c 


65270 


206 


M 


66180 


216 


C 


64856 


196 


c 


65272 


214 


C 


66185 


216 


C 


64857 


196 


c 


65273 


993 


C 


66220 


218 


C 


64858 


196 


c 


65275 


214 


C 


66225 


216 


C 


64859 


197 


c 


65280 


215 


C 


66250 


215 


C 


64861 


993 


c 


65285 


216 


C 


66500 


214 


C 


64862 


993 


c 


65286 


214 


C 


66505 


214 


C 


64864 


196 


c 


65290 


220 


C 


66600 


215 


C 


64865 


196 


c 


65400 


215 


C 


66605 


215 


C 


64866 


196 


c 


65410 


221 


C 


66625 


215 


C 


64868 


196 


c 


65420 


214 


C 


66630 


215 


C 


64870 


196 


c 


65426 


215 


C 


66635 


215 


c 


64872 


197 


c 


65430 


205 


C 


66680 


215 


c 


64874 


197 


c 


65435 


221 


C 


66682 


215 


c 


64876 


197 


c 


65436 


214 


C 


66700 


214 


c 


64885 


196 


c 


65450 


214 


C 


66710 


214 


c 


64886 


196 


c 


65600 


214 


C 


66720 


214 


c 


64890 


196 


c 


65710 


217 


C 


66740 


215 


c 


64891 


196 


c 


65730 


217 


C 


66761 


211 


c 


64892 


196 


c 


65750 


217 


C 


66762 


211 


c 


64893 


196 


c 


65755 


217 


C 


66770 


211 


c 


64895 


196 


c 


65760 


216 


c 


66820 


214 


c 


64896 


196 


c 


65765 


216 


C 


66821 


211 


c 


64897 


196 


c 


65767 


216 


C 


66825 


215 


c 


64898 


196 


c 


65770 


216 


C 


66830 


215 


c 


64901 


196 


c 


65771 


214 


C 


66840 


213 


c 


64902 


196 


c 


65772 


214 


c 


66850 


213 


c 


64905 


196 


c 


65775 


215 


c 


66852 


213 


c 


64907 


196 


c 


65800 


221 


C 


66920 


213 


c 


64999 


201 


c 


65805 


221 


C 


66930 


213 


c 


65091 


223 


c 


65810 


214 


c 


66940 


213 


c 


65093 


223 


c 


65815 


214 


c 


66983 


213 


c 


65101 


223 


c 


65820 


215 


C 


66984 


213 


c 


65103 


223 


c 


65850 


216 


C 


66985 


213 


c 


65105 


223 


c 


65855 


211 


c 


66986 


213 


c 


65110 


223 


c 


65860 


211 


c 


66999 


214 


c 


65112 


223 


c 


65865 


215 


C 


67005 


218 


c 


65114 


223 


c 


65870 


215 


C 


67010 


218 


c 


65125 


222 


c 


65875 


215 


C 


67015 


218 


c 


65130 


223 


c 


65880 


215 


C 


67025 


218 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



157 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


67028 


222 


C 


67450 


236 


C 


67999 


221 


C 


67030 


218 


C 


67500 


205 


C 


68020 


221 


C 


67031 


211 


c 


67505 


221 


C 


68040 


221 


C 


67036 


219 


c 


67515 


205 


C 


68100 


206 


M 


67038 


219 


c 


67550 


223 


C 


68110 


Oil 


c 


67039 


219 


c 


67560 


223 


c 


68115 


Oil 


C 


67040 


219 


c 


67570 


993 


c 


68130 


215 


C 


67101 


218 


c 


67599 


221 


c 


68135 


on 


c 


67105 


212 


c 


67700 


221 


c 


68200 


205 


C 


67107 


219 


c 


67710 


221 


c 


68320 


223 


c 


67108 


■ 219 


c 


67715 


221 


c 


68325 


223 


c 


67109 - 


' 218 


c 


67800 


221 


c 


68326 


223 


C 


67110 


218 


c 


67801 


221 


c 


68328 


223 


C 


67112 


219 


c 


67805 


221 


c 


68330 


215 


C 


67115 


218 


c 


67808 


222 


c 


68335 


223 


c 


67120 


218 


c 


67810 


205 


c 


68340 


223 


C 


67121 


218 


c 


67820 


205 


c 


68360 


215 


C 


67141 


218 


c 


67825 


221 


c 


68362 


215 


C 


67145 


212 


c 


67830 


221 


c 


68399 


205 


C 


67208 


218 


c 


67835 


223 


c 


68400 


221 


C 


67210 


212 


c 


67840 


221 


c 


68420 


221 


C 


67218 


218 


c 


67850 


221 


c 


68440 


221 


C 


67227 


218 


c 


67875 


221 


c 


68500 


223 


C 


67228 


212 


c 


67880 


221 


c 


68505 


223 


c 


67250 


223 


c 


67882 


223 


c 


68510 


222 


c 


67255 


223 


c 


67900 


222 


c 


68520 


223 


C 


67299 


218 


c 


67901 


223 


c 


68525 


222 


c 


67311 


220 


c 


67902 


223 


c 


68530 


222 


C 


67312 


220 


c 


67903 


223 


c 


68540 


223 


C 


67314 


220 


c 


67904 


223 


c 


68550 


223 


c 


67316 


220 


c 


67906 


223 


c 


68700 


222 


C 


67318 


220 


c 


67908 


223 


c 


68705 


221 


c 


67320 


220 


c 


67909 


223 


c 


68720 


223 


C 


67331 


220 


c 


67911 


223 


c 


68745 


223 


C 


67332 


220 


c 


67914 


222 


c 


68750 


223 


C 


67334 


220 


c 


67915 


222 


c 


68760 


221 


C 


67335 


222 


c 


67916 


223 


c 


68761 


206 


M 


67340 


220 


c 


67917 


223 


c 


68770 


223 


C 


67343 


220 


c 


67921 


222 


c 


68800 


221 


C 


67345 


221 


c 


67922 


222 


c 


68820 


221 


C 


67350 


Oil 


c 


67923 


223 


c 


68825 


221 


C 


67399 


221 


c 


67924 


773 


c 


68830 


221 


C 


67400 


223 


c 


67930 


221 


c 


68840 


221 


C 


67405 


223 


c 


67935 


222 


c 


68850 


326 


c 


67412 


223 


c 


67938 


221 


c 


68899 


221 


c 


67413 


223 


c 


67950 


223 


c 


69000 


004 


c 


67414 


993 


c 


67961 


223 


c 


69005 


004 


C 


67415 


221 


c 


67966 


223 


c 


69020 


004 


C 


67420 


236 


c 


67971 


223 


c 


69090 


421 


c 


67430 


236 


c 


67973 


223 


c 


69100 


010 


C 


67440 


236 


c 


67974 


223 


c 


69105 


233 


c 


67445 


993 


c 


67975 


223 


c 


69110 


on 


c 


158 














Final 


Report 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


69120 


234 


C 


69645 


236 


C 


70260 


281 


M 


69140 


235 


c 


69646 


236 


C 


70300 


281 


M 


69145 


Oil 


c 


69650 


236 


C 


70310 


281 


M 


69150 


236 


c 


69660 


236 


C 


70320 


281 


M 


69155 


993 


c 


69661 


236 


C 


70328 


281 


M 


69200 


239 


c 


69662 


236 


C 


70330 


281 


M 


69205 


239 


c 


69666 


236 


C 


70332 


272 


M 


69210 


239 


c 


69667 


236 


C 


70336 


277 


M 


69220 


007 


c 


69670 


236 


C 


70350 


281 


M 


69222 


233 


c 


69676 


236 


C 


70355 


281 


M 


69300 


. 235 


c 


69700 


236 


C 


70360 


281 


M 


69310 - 


236 


c 


69710 


236 


C 


70370 


260 


M 


69320 


236 


c 


69711 


236 


C 


70371 


260 


M 


69399 


239 


c 


69720 


236 


C 


70373 


283 


M 


69400 


233 


c 


69725 


236 


C 


70380 


281 


M 


69401 


231 


M 


69740 


236 


C 


70390 


283 


M 


69405 


233 


c 


69745 


236 


C 


70450 


278 


M 


69410 


233 


c 


69799 


233 


C 


70460 


278 


M 


69420 


233 


c 


69801 


236 


C 


70470 


278 


M 


69421 


233 


c 


69802 


236 


C 


70480 


278 


M 


69424 


233 


c 


69805 


236 


c 


70481 


278 


M 


69433 


233 


c 


69806 


236 


C 


70482 


278 


M 


69436 


233 


c 


69820 


236 


C 


70486 


278 


M 


69440 


235 


c 


69840 


236 


c 


70487 


278 


M 


69450 


235 


c 


69905 


236 


C 


70488 


278 


M 


69501 


236 


c 


69910 


236 


C 


70490 


278 


M 


69502 


993 


c 


69915 


236 


c 


70491 


278 


M 


69505 


236 


c 


69930 


230 


C 


70492 


278 


M 


69511 


236 


c 


69949 


233 


C 


70540 


277 


M 


69530 


236 


c 


69950 


993 


C 


70541 


271 


M 


69535 


993 


c 


69955 


236 


C 


70551 


277 


M 


69540 


233 


c 


69960 


236 


C 


70552 


277 


M 


69550 


236 


c 


69970 


993 


C 


70553 


277 


M 


69552 


236 


c 


69979 


233 


C 


71010 


281 


M 


69554 


993 


c 


70010 


261 


M 


71015 


281 


M 


69601 


236 


c 


70015 


261 


M 


71020 


281 


M 


69602 


236 


c 


70030 


281 


M 


71021 


281 


M 


69603 


236 


c 


70100 


281 


M 


71022 


281 


M 


69604 


236 


c 


70110 


281 


M 


71023 


260 


M 


69605 


236 


c 


70120 


281 


M 


71030 


281 


M 


69610 


234 


c 


70130 


281 


M 


71034 


260 


M 


69620 


235 


c 


70134 


281 


M 


71035 


281 


M 


69631 


236 


c 


70140 


281 


M 


71036 


260 


M 


69632 


236 


c 


70150 


281 


M 


71038 


260 


M 


69633 


236 


c 


70160 


281 


M 


71040 


283 


M 


69635 


236 


c 


70170 


283 


M 


71060 


283 


M 


69636 


236 


c 


70190 


281 


M 


71090 


260 


M 


69637 


236 


c 


70200 


281 


M 


71100 


281 


M 


69641 


236 


c 


70210 


281 


M 


71101 


281 


M 


69642 


236 


c 


70220 


281 


M 


71110 


281 


M 


69643 


236 


c 


70240 


281 


M 


71111 


281 


M 


69644 


236 


c 


70250 


281 


M 


71120 


281 


M 



The Development of a Physician Prospective Payment System for Ambulatory Care 



159 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


71130 


281 


M 


72265 


261 


M 


73720 


277 


M 


71250 


278 


M 


72270 


261 


M 


73721 


277 


M 


71260 


278 


M 


72285 


261 


M 


73725 


271 


M 


71270 


278 


M 


72295 


261 


M 


74000 


281 


M 


71550 


277 


M 


73000 


281 


M 


74010 


281 


M 


71555 


271 


M 


73010 


281 


M 


74020 


281 


M 


72010 


281 


M 


73020 


281 


M 


74022 


281 


M 


72020 


281 


M 


73030 


281 


M 


74150 


278 


M 


72040 


281 


M 


73040 


272 


M 


74160 


278 


M 


72050 


281 


M 


73050 


281 


M 


74170 


278 


M 


72052 


. 281 


M 


73060 


281 


M 


74181 


277 


M 


72069 - 


281 


M 


73070 


281 


M 


74185 


271 


M 


72070 


281 


M 


73080 


281 


M 


74190 


283 


M 


72072 


281 


M 


73085 


272 


M 


74210 


280 


M 


72074 


281 


M 


73090 


281 


M 


74220 


280 


M 


72080 


281 


M 


73092 


281 


M 


74230 


280 


M 


72090 


281 


M 


73100 


281 


M 


74235 


256 


M 


72100 


281 


M 


73110 


281 


M 


74240 


280 


M 


72110 


281 


M 


73115 


272 


M 


74241 


280 


M 


72114 


281 


M 


73120 


281 


M 


74245 


280 


M 


72120 


281 


M 


73130 


281 


M 


74246 


280 


M 


72125 


278 


M 


73140 


281 


M 


74247 


280 


M 


72126 


278 


M 


73200 


278 


M 


74249 


280 


M 


72127 


278 


M 


73201 


278 


M 


74250 


280 


M 


72128 


278 


M 


73202 


278 


M 


74251 


280 


M 


72129 


278 


M 


73220 


277 


M 


74260 


280 


M 


72130 


278 


M 


73221 


277 


M 


74270 


280 


M 


72131 


278 


M 


73225 


271 


M 


74280 


280 


M 


72132 


278 


M 


73500 


281 


M 


74283 


280 


M 


72133 


278 


M 


73510 


281 


M 


74290 


280 


M 


72141 


277 


M 


73520 


281 


M 


74291 


280 


M 


72142 


277 


M 


73525 


272 


M 


74300 


283 


M 


72146 


277 


M 


73530 


281 


M 


74301 


993 


C 


72147 


277 


M 


73540 


281 


M 


74305 


283 


M 


72148 


277 


M 


73550 


281 


M 


74320 


283 


M 


72149 


277 


M 


73560 


281 


M 


74327 


256 


M 


72156 


277 


M 


73562 


281 


M 


74328 


283 


M 


72157 


277 


M 


73564 


281 


M 


74329 


283 


M 


72158 


277 


M 


73565 


281 


M 


74330 


283 


M 


72159 


271 


M 


73580 


272 


M 


74340 


260 


M 


72170 


281 


M 


73590 


281 


M 


74350 


283 


M 


72190 


281 


M 


73592 


281 


M 


74355 


283 


M 


72192 


278 


M 


73600 


281 


M 


74360 


256 


M 


72193 


278 


M 


73610 


281 


M 


74363 


256 


M 


72194 


278 


M 


73615 


272 


M 


74400 


262 


M 


72196 


277 


M 


73620 


281 


M 


74405 


262 


M 


72198 


271 


M 


73630 


281 


M 


74410 


262 


M 


72200 


281 


M 


73650 


281 


M 


74415 


262 


M 


72202 


281 


M 


73660 


281 


M 


74420 


262 


M 


72220 


281 


M 


73700 


278 


M 


74425 


262 


M 


72240 


261 


M 


73701 


278 


M 


74430 


262 


M 


72255 


261 


M 


73702 


278 


M 


74440 


262 


M 


160 














Final 


Report 



■*(*^ 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


74445 


262 


M 


75766 


270 


M 


76020 


281 


M 


74450 


262 


M 


75774 


270 


M 


76040 


281 


M 


74455 


262 


M 


75790 


270 


M 


76061 


281 


M 


74470 


283 


M 


75801 


283 


M 


76062 


281 


M 


74475 


256 


M 


75803 


283 


M 


76065 


281 


M 


74480 


256 


M 


75805 


283 


M 


76066 


281 


M 


74485 


256 


M 


75807 


283 


M 


76070 


278 


M 


74710 


281 


M 


75809 


283 


M 


76075 


281 


M 


74740 


283 


M 


75810 


270 


M 


76080 


283 


M 


74742 


283 


M 


75820 


270 


M 


76086 


283 


M 


74775 . 


262 


M 


75822 


270 


M 


76088 


283 


M 


75500 - 


270 


M 


75825 


270 


M 


76090 


279 


M 


75505 


270 


M 


75827 


270 


M 


76091 


279 


M 


75507 


270 


M 


75831 


270 


M 


76092 


279 


M 


75519 


270 


M 


75833 


270 


M 


76093 


277 


M 


75523 


270 


M 


75840 


270 


M 


76094 


277 


M 


75527 


270 


M 


75842 


270 


M 


76095 


283 


M 


75552 


277 


M 


75860 


270 


M 


76096 


283 


M 


75553 


277 


M 


75870 


270 


M 


76098 


281 


M 


75554 


277 


M 


75872 


270 


M 


76100 


281 


M 


75555 


277 


M 


75880 


270 


M 


76101 


281 


M 


75556 


277 


M 


75885 


270 


M 


76102 


281 


M 


75600 


270 


M 


75887 


270 


M 


76120 


281 


M 


75605 


270 


M 


75889 


270 


M 


76125 


281 


M 


75625 


270 


M 


75891 


270 


M 


76140 


281 


P 


75630 


270 


M 


75893 


270 


M 


76150 


281 


M 


75650 


270 


M 


75894 


077 


M 


76350 


281 


M 


75658 


270 


M 


75896 


077 


M 


76355 


278 


M 


75660 


270 


M 


75898 


283 


M 


76360 


278 


M 


75662 


270 


M 


75900 


993 


M 


76365 


278 


M 


75665 


270 


M 


75940 


077 


M 


76370 


278 


M 


75671 


270 


M 


75960 


077 


M 


76375 


278 


M 


75676 


270 


M 


75961 


077 


M 


76380 


278 


M 


75680 


270 


M 


75962 


077 


M 


76400 


277 


M 


75685 


270 


M 


75964 


077 


M 


76499 


281 


M 


75705 


270 


M 


75966 


077 


M 


76506 


275 


M 


75710 


270 


M 


75968 


077 


M 


76511 


275 


M 


75716 


270 


M 


75970 


077 


M 


76512 


275 


M 


75722 


270 


M 


75978 


077 


M 


76513 


275 


M 


75724 


270 


M 


75980 


256 


M 


76516 


275 


M 


75726 


270 


M 


75982 


256 


M 


76519 


275 


M 


75731 


270 


M 


75984 


256 


M 


76529 


275 


M 


75733 


270 


M 


75989 


260 


M 


76536 


275 


M 


75736 


270 


M 


75992 


077 


M 


76604 


275 


M 


75741 


270 


M 


75993 


077 


M 


76645 


275 


M 


75743 


270 


M 


75994 


077 


M 


76700 


275 


M 


75746 


270 


M 


75995 


077 


M 


76705 


275 


M 


75750 


270 


M 


75996 


077 


M 


76770 


275 


M 


75752 


270 


M 


76000 


260 


M 


76775 


275 


M 


75754 


270 


M 


76001 


260 


M 


76778 


275 


M 


75756 


270 


M 


76003 


260 


M 


76800 


275 


M 


75762 


270 


M 


76010 


281 


M 


76805 


273 


M 



The Development of a Physician Prospective Payment System for Ambulatory Care 



161 



APPENDIX E 


















Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


76810 


273 


M 


77370 


245 


C 


78017 


265 


M 


76815 


273 


M 


77399 


245 


C 


78018 


265 


M 


76816 


273 


M 


77401 


250 


C 


78070 


265 


M 


76818 


273 


M 


77402 


250 


C 


78075 


265 


M 


76825 


074 


M 


77403 


250 


C 


78099 


267 


M 


76826 


074 


M 


77404 


250 


C 


78102 


266 


M 


76827 


074 


M 


77406 


250 


C 


78103 


266 


M 


76828 


074 


M 


77407 


250 


C 


78104 


266 


M 


76830 


275 


M 


77408 


250 


C 


78110 


264 


M 


76856 


275 


M 


77409 


250 


C 


78111 


264 


M 


76857 


. 275 


M 


77411 


250 


C 


78120 


264 


M 


76870 . 


275 


M 


77412 


250 


C 


78121 


263 


M 


76872 


275 


M 


77413 


250 


c 


78122 


263 


M 


76880 


275 


M 


77414 


250 


c 


78130 


263 


M 


76930 


276 


M 


77416 


250 


c 


78135 


263 


M 


76932 


276 


M 


77417 


281 


M 


78140 


263 


M 


76934 


276 


M 


77419 


249 


c 


78160 


263 


M 


76936 


276 


M 


77420 


249 


c 


78162 


263 


M 


76938 


276 


M 


77425 


249 


c 


78170 


263 


M 


76941 


273 


M 


77430 


249 


c 


78172 


263 


P 


76942 


276 


M 


77431 


249 


c 


78185 


266 


M 


76945 


273 


M 


77432 


249 


c 


78190 


263 


M 


76946 


273 


M 


77470 


250 


c 


78191 


263 


M 


76948 


273 


M 


77499 


249 


c 


78192 


267 


M 


76950 


276 


M 


77600 


251 


M 


78193 


267 


M 


76960 


276 


M 


77605 


251 


M 


78195 


265 


M 


76965 


276 


M 


77610 


251 


M 


78199 


267 


M 


76970 


275 


M 


77615 


251 


M 


78201 


266 


M 


76975 


275 


M 


77620 


251 


M 


78202 


266 


M 


76986 


275 


M 


77750 


248 


M 


78205 


267 


M 


76999 


275 


M 


77761 


248 


M 


78215 


266 


M 


77261 


245 


C 


77762 


248 


M 


78216 


266 


M 


77262 


245 


C 


77763 


248 


M 


78220 


265 


M 


77263 


245 


C 


11116 


248 


M 


78223 


265 


M 


77280 


247 


M 


11111 


248 


M 


78230 


266 


M 


77285 


247 


M 


llllS 


248 


M 


78231 


266 


M 


77290 


247 


M 


77781 


248 


M 


78232 


265 


M 


77295 


247 


M 


77782 


248 


M 


78258 


265 


M 


77299 


246 


M 


77783 


248 


M 


78261 


266 


M 


77300 


246 


M 


77784 


248 


M 


78262 


265 


M 


77305 


246 


M 


77789 


248 


M 


78264 


265 


M 


77310 


246 


M 


77790 


246 


M 


78270 


264 


M 


77315 


246 


M 


77799 


248 


M 


78271 


264 


M 


77321 


246 


M 


78000 


264 


M 


78272 


264 


M 


77326 


246 


M 


78001 


263 


M 


78276 


265 


M 


77327 


246 


M 


78003 


263 


M 


78278 


265 


M 


77328 


246 


M 


78006 


266 


M 


78280 


265 


M 


77331 


246 


M 


78007 


265 


M 


78282 


264 


M 


77332 


246 


M 


78010 


266 


M 


78290 


266 


M 


77333 


246 


M 


78011 


266 


M 


78291 


265 


M 


77334 


246 


M 


78015 


266 


M 


78299 


267 


M 


77336 


245 


C 


78016 


265 


M 


78300 


266 


M 


162 














Final 


Report 



vrw?-- 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


78305 


266 


M 


78645 


265 


M 


80008 


365 


C 


78306 


266 


M 


78647 


269 


M 


80009 


365 


C 


78310 


264 


M 


78650 


265 


M 


80010 


365 


C 


78315 


265 


M 


78652 


264 


M 


80011 


365 


c 


78320 


268 


M 


78655 


266 


M 


80012 


365 


C 


78350 


263 


M 


78660 


266 


M 


80016 


365 


C 


78351 


263 


M 


78699 


267 


M 


80018 


365 


C 


78399 


267 


M 


78700 


266 


M 


80019 


365 


C 


78414 


263 


M 


78701 


266 


M 


80050 


366 


C 


78428 


266 


M 


78704 


266 


M 


80055 


366 


C 


78445 . 


266 


M 


78707 


266 


M 


80058 


366 


C 


78455 . 


263 


M 


78710 


268 


M 


80059 


366 


C 


78457 


266 


M 


78715 


266 


M 


80061 


366 


c 


78458 


266 


M 


78725 


264 


M 


80072 


366 


C 


78459 


282 


C 


78726 


264 


M 


80090 


366 


C 


78460 


266 


M 


78727 


266 


M 


80091 


366 


C 


78461 


265 


M 


78730 


266 


M 


80092 


366 


C 


78464 


269 


M 


78740 


265 


M 


80100 


367 


c 


78465 


269 


M 


78760 


266 


M 


80101 


367 


C 


78466 


266 


M 


78761 


266 


M 


80102 


367 


C 


78468 


265 


M 


78799 


267 


M 


80103 


367 


C 


78469 


268 


M 


78800 


265 


M 


80150 


368 


c 


78472 


265 


M 


78801 


265 


M 


80152 


368 


C 


78473 


265 


M 


78802 


265 


M 


80154 


368 


C 


78478 


266 


M 


78803 


269 


M 


80156 


368 


c 


78480 


266 


M 


78805 


265 


M 


80158 


368 


C 


78481 


266 


M 


78806 


265 


M 


80160 


368 


C 


78483 


265 


M 


78807 


269 


M 


80162 


368 


C 


78499 


267 


M 


78810 


282 


C 


80164 


368 


c 


78580 


266 


M 


78890 


267 


P 


80166 


368 


c 


78581 


265 


M 


78891 


267 


P 


80168 


368 


C 


78582 


265 


M 


78990 


402 


C 


80170 


368 


C 


78584 


265 


M 


78999 


267 


M 


80172 


367 


C 


78585 


265 


M 


79000 


253 


M 


80174 


368 


C 


78586 


266 


M 


79001 


254 


M 


80176 


368 


C 


78587 


266 


M 


79020 


253 


M 


80178 


368 


C 


78591 


266 


M 


79030 


253 


M 


80182 


368 


C 


78593 


266 


M 


79035 


253 


M 


80184 


368 


C 


78594 


265 


M 


79100 


254 


M 


80185 


368 


C 


78596 


265 


M 


79200 


253 


M 


80186 


368 


c 


78599 


267 


M 


79300 


254 


P 


80188 


368 


C 


78600 


266 


M 


79400 


255 


M 


80190 


368 


C 


78601 


266 


M 


79420 


254 


P 


80192 


368 


C 


78605 


266 


M 


79440 


253 


M 


80194 


368 


C 


78606 


265 


M 


79900 


402 


C 


80196 


368 


C 


78607 


269 


M 


79999 


253 


M 


80198 


368 


C 


78608 


282 


C 


80002 


365 


C 


80200 


368 


C 


78609 


282 


C 


80003 


365 


C 


80202 


368 


C 


78610 


266 


M 


80004 


365 


C 


80299 


368 


C 


78615 


265 


M 


80005 


365 


C 


80400 


361 


c 


78630 


265 


M 


80006 


365 


C 


80402 


361 


c 


78635 


265 


M 


80007 


365 


c 


80406 


361 


C 



The Development of a Physician Prospective Payment System for Ambulatory Care 



163 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


80408 


361 


C 


82104 


363 


C 


82387 


363 


C 


80410 


361 


C 


82105 


363 


C 


82390 


363 


C 


80412 


361 


C 


82106 


363 


c 


82397 


362 


C 


80414 


361 


C 


82108 


367 


c 


82415 


368 


C 


80415 


361 


C 


82128 


363 


c 


82435 


364 


C 


80416 


366 


C 


82130 


363 


c 


82436 


364 


C 


80417 


366 


C 


8213! 


363 


c 


82438 


362 


C 


80418 


361 


C 


82135 


363 


c 


82441 


367 


C 


80420 


361 


c 


82140 


362 


c 


82465 


364 


C 


80422 


361 


c 


82143 


363 


c 


82480 


363 


C 


80424 


. 361 


c 


82145 


368 


c 


82482 


363 


C 


80426 - 


361 


c 


82150 


362 


c 


82485 


36] 


C 


80428 


361 


c 


82154 


361 


c 


82486 


363 


C 


80430 


361 


c 


82157 


361 


c 


82487 


363 


c 


80432 


361 


c 


82160 


361 


c 


82488 


363 


C 


80434 


361 


c 


82163 


361 


c 


82489 


363 


C 


80435 


361 


c 


82164 


363 


c 


82491 


362 


C 


80436 


361 


c 


82172 


363 


c 


82495 


367 


C 


80438 


361 


c 


82173 


363 


c 


82507 


363 


C 


80439 


361 


c 


82175 


367 


c 


82520 


368 


c 


80440 


361 


c 


82180 


363 


c 


82525 


367 


C 


80500 


351 


M 


82190 


363 


c 


82528 


361 


C 


80502 


351 


M 


82205 


367 


c 


82530 


362 


c 


81000 


373 


c 


82232 


361 


c 


82533 


361 


c 


81001 


373 


c 


82239 


363 


c 


82536 


360 


c 


81002 


374 


c 


82240 


363 


c 


82537 


360 


c 


81003 


374 


c 


82250 


364 


c 


82538 


360 


c 


81005 


373 


c 


82251 


364 


c 


82539 


360 


c 


81007 


373 


c 


82252 


364 


c 


82540 


364 


c 


81015 


373 


c 


82270 


362 


c 


82550 


364 


c 


81020 


373 


c 


82273 


362 


c 


82552 


364 


c 


81025 


373 


c 


82286 


363 


c 


82553 


362 


c 


81050 


373 


c 


82300 


367 


c 


82554 


363 


c 


81099 


362 


c 


82306 


363 


c 


82565 


362 


c 


82000 


362 


c 


82307 


361 


c 


82570 


362 


c 


82003 


368 


c 


82308 


361 


c 


82575 


362 


c 


82009 


362 


c 


82310 


364 


c 


82585 


363 


c 


82010 


362 


c 


82330 


362 


c 


82595 


362 


c 


82013 


363 


c 


82331 


362 


c 


82600 


367 


c 


82024 


361 


c 


82340 


362 


c 


82607 


361 


c 


82030 


361 


c 


82355 


363 


c 


82608 


363 


c 


82040 


364 


c 


82360 


363 


c 


82615 


363 


c 


82042 


362 


c 


82365 


363 


c 


82626 


363 


c 


82043 


373 


c 


82370 


363 


c 


82627 


363 


c 


82044 


373 


c 


82374 


364 


c 


82633 


361 


c 


82055 


362 


c 


82375 


362 


c 


82634 


361 


c 


82075 


362 


c 


82376 


362 


c 


82638 


363 


c 


82085 


363 


c 


82378 


362 


c 


82646 


367 


c 


82088 


361 


c 


82380 


362 


c 


82649 


367 


c 


82091 


361 


c 


82382 


360 


c 


82651 


361 


c 


82101 


367 


c 


82383 


360 


c 


82652 


363 


c 


82103 


363 


c 


82384 


360 


c 


82654 


368 


c 


164 














Final 


Report 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


82664 


363 


C 


82960 


362 


C 


83550 


362 


C 


82666 


361 


c 


82961 


363 


C 


83570 


363 


C 


82668 


363 


c 


82962 


364 


C 


83582 


360 


C 


82670 


360 


c 


82963 


363 


c 


83586 


360 


C 


82671 


361 


c 


82965 


363 


c 


83593 


360 


C 


82672 


360 


c 


82975 


363 


c 


83605 


362 


C 


82677 


360 


c 


82977 


364 


c 


83615 


364 


C 


82679 


361 


c 


82978 


363 


c 


83625 


363 


C 


82690 


368 


c 


82979 


363 


c 


83632 


363 


C 


82693 


367 


c 


82980 


368 


c 


83633 


362 


C 


82696 


. 361 


c 


82985 


363 


c 


83634 


362 


c 


82705 - 


362 


c 


83001 


361 


c 


83655 


367 


c 


82710 


363 


c 


83002 


361 


c 


83661 


363 


c 


82715 


363 


c 


83003 


361 


c 


83662 


363 


c 


82725 


363 


c 


83004 


360 


c 


83670 


363 


c 


82728 


362 


c 


83008 


361 


c 


83681 


363 


c 


82735 


367 


c 


83010 


363 


c 


83690 


362 


c 


82742 


368 


c 


83012 


363 


c 


83715 


363 


c 


82746 


362 


c 


83015 


367 


c 


83717 


363 


c 


82747 


371 


c 


83018 


367 


c 


83718 


362 


c 


82757 


363 


c 


83020 


363 


c 


83719 


363 


c 


82759 


363 


c 


83026 


371 


c 


83721 


362 


c 


82760 


363 


c 


83030 


363 


c 


83727 


361 


c 


82775 


363 


c 


83033 


363 


c 


83735 


362 


c 


82776 


363 


c 


83036 


363 


c 


83775 


363 


c 


82784 


363 


c 


83045 


363 


c 


83785 


367 


c 


82785 


363 


c 


83050 


363 


c 


83790 


363 


c 


82787 


357 


c 


83051 


363 


c 


83805 


363 


c 


82792 


362 


c 


83055 


363 


c 


83825 


367 


c 


82800 


362 


c 


83060 


363 


c 


83835 


361 


c 


82801 


362 


c 


83065 


363 


c 


83840 


368 


c 


82802 


362 


c 


83068 


363 


c 


83857 


363 


c 


82803 


362 


c 


83069 


363 


c 


83858 


368 


c 


82804 


362 


c 


83070 


363 


c 


83864 


363 


c 


82805 


362 


c 


83071 


363 


c 


83866 


363 


c 


82810 


362 


c 


83088 


363 


c 


83872 


362 


c 


82812 


362 


c 


83150 


361 


c 


83873 


363 


c 


82817 


362 


c 


83491 


361 


c 


83874 


363 


c 


82820 


371 


c 


83497 


360 


c 


83883 


357 


c 


82926 


363 


c 


83498 


361 


c 


83885 


367 


c 


82928 


363 


c 


83499 


361 


c 


83887 


368 


c 


82938 


360 


c 


83500 


361 


c 


83890 


357 


c 


82941 


360 


c 


83505 


361 


c 


83892 


357 


c 


82943 


361 


c 


83516 


356 


c 


83894 


357 


c 


82946 


363 


c 


83518 


356 


c 


83896 


357 


c 


82947 


377 


c 


83519 


356 


c 


83898 


357 


c 


82948 


374 


c 


83520 


356 


c 


83912 


363 


c 


82950 


364 


c 


83525 


361 


c 


83915 


363 


c 


82951 


364 


c 


83526 


363 


c 


83916 


363 


c 


82952 


364 


c 


83527 


361 


c 


83918 


367 


c 


82953 


363 


c 


83528 


363 


c 


83925 


368 


c 


82955 


363 


c 


83540 


362 


c 


83930 


362 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



165 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


83935 


362 


C 


84234 


361 


C 


84577 


363 


C 


83937 


361 


C 


84235 


361 


C 


84578 


374 


C 


83945 


363 


c 


84238 


363 


c 


84580 


363 


C 


83970 


361 


c 


84244 


361 


c 


84583 


363 


C 


83986 


362 


c 


84246 


361 


c 


84585 


361 


C 


83992 


368 


c 


84252 


363 


c 


84586 


361 


C 


84022 


368 


c 


84255 


363 


c 


84588 


361 


C 


84030 


363 


c 


84260 


361 


c 


84589 


363 


c 


84035 


362 


c 


84270 


363 


c 


84590 


363 


C 


84060 


364 


c 


84275 


363 


c 


84597 


363 


C 


84061 


. 351 


M 


84285 


367 


c 


84600 


363 


c 


84066 . 


363 


C 


84295 


364 


C 


84620 


363 


c 


84075 


364 


C 


84300 


362 


c 


84630 


367 


c 


84078 


362 


c 


84305 


361 


c 


84681 


363 


c 


84080 


363 


c 


84307 


361 


c 


84702 


362 


C 


84081 


363 


c 


84311 


362 


c 


84703 


362 


c 


84085 


363 


c 


84315 


362 


c 


84830 


361 


C 


84087 


363 


c 


84375 


363 


c 


84999 


362 


C 


84100 


364 


c 


84392 


373 


c 


85002 


369 


C 


84105 


362 


c 


84402 


360 


c 


85007 


372 


c 


84106 


363 


c 


84403 


361 


c 


85008 


372 


c 


84110 


363 


c 


84425 


363 


c 


85009 


372 


C 


84119 


363 


c 


84430 


367 


C 


85013 


376 


c 


84120 


363 


c 


84432 


361 


c 


85014 


371 


c 


84126 


363 


c 


84436 


360 


c 


85018 


376 


C 


84127 


361 


c 


84437 


360 


c 


85021 


371 


C 


84132 


364 


c 


84439 


360 


c 


85022 


372 


C 


84133 


362 


c 


84442 


360 


c 


85023 


372 


c 


84134 


363 


c 


84443 


360 


c 


85024 


371 


c 


84135 


361 


c 


84444 


361 


c 


85025 


371 


c 


84138 


361 


c 


84445 


361 


c 


85027 


371 


c 


84140 


361 


c 


84446 


363 


c 


85029 


371 


c 


84143 


361 


c 


84449 


361 


c 


85030 


371 


c 


84144 


360 


c 


84450 


364 


c 


85031 


372 


c 


84146 


361 


c 


84460 


364 


c 


85041 


371 


c 


84150 


361 


c 


84466 


362 


c 


85044 


372 


C 


84153 


362 


c 


84478 


364 


c 


85045 


371 


C 


84155 


364 


c 


84479 


360 


c 


85048 


372 


c 


84160 


364 


c 


84480 


360 


c 


85060 


351 


M 


84165 


363 


c 


84481 


360 


c 


85095 


002 


C 


84175 


362 


c 


84482 


360 


c 


85097 


351 


M 


84181 


356 


c 


84485 


363 


c 


85102 


002 


c 


84182 


357 


c 


84488 


363 


c 


85130 


372 


c 


84201 


361 


c 


84490 


363 


c 


85170 


369 


c 


84202 


363 


c 


84510 


363 


c 


85175 


369 


c 


84203 


363 


c 


84520 


364 


c 


85210 


369 


c 


84206 


361 


c 


84525 


374 


c 


85220 


370 


c 


84207 


363 


c 


84540 


362 


c 


85230 


370 


C 


84210 


363 


c 


84545 


362 


c 


85240 


370 


C 


84220 


363 


c 


84550 


364 


c 


85244 


370 


c 


84228 


368 


c 


84555 


362 


c 


85245 


370 


c 


84233 


361 


c 


84560 


362 


c 


85246 


370 


c 


166 














Final 


Report 



• 



-;'»*«.« 






Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


85247 


370 


C 


85595 


371 


C 


86289 


362 


C 


85250 


370 


C 


85597 


370 


C 


86290 


362 


C 


85260 


370 


c 


85610 


369 


C 


86291 


362 


c 


85270 


370 


c 


85611 


369 


C 


86293 


362 


c 


85280 


370 


c 


85612 


370 


c 


86295 


362 


C 


85290 


370 


c 


85613 


370 


c 


86296 


362 


c 


85291 


370 


c 


85635 


372 


c 


86299 


362 


C 


85292 


370 


c 


85651 


371 


c 


86302 


357 


c 


85293 


370 


c 


85652 


371 


c 


86303 


357 


c 


85300 


370 


c 


85660 


371 


c 


86306 


357 


C 


85301 


370 


c 


85670 


369 


c 


86308 


356 


c 


85302 - 


370 


c 


85675 


369 


c 


86309 


356 


C 


85303 


370 


c 


85705 


370 


c 


86310 


357 


c 


85305 


370 


c 


85720 


370 


c 


86311 


357 


c 


85306 


370 


c 


85730 


369 


c 


86313 


358 


c 


85335 


370 


c 


85732 


369 


c 


86315 


358 


c 


85337 


370 


c 


85810 


372 


c 


86316 


363 


c 


85345 


369 


c 


85820 


372 


C 


86317 


357 


C 


85347 


369 


c 


85999 


371 


c 


86318 


357 


c 


85348 


369 


c 


86000 


356 


c 


86320 


363 


C 


85360 


372 


c 


86003 


356 


c 


86325 


363 


C 


85362 


369 


c 


86005 


356 


c 


86327 


363 


c 


85366 


369 


c 


86021 


357 


c 


86329 


357 


c 


85370 


369 


c 


86022 


357 


c 


86331 


357 


C 


85378 


369 


c 


86023 


357 


C 


86332 


357 


C 


85379 


369 


c 


86038 


362 


c 


86334 


357 


C 


85384 


369 


c 


86039 


362 


c 


86337 


361 


C 


85385 


369 


c 


86060 


357 


c 


86340 


361 


c 


85390 


369 


c 


86063 


356 


C 


86341 


357 


C 


85400 


370 


c 


86077 


351 


M 


86343 


357 


c 


85410 


370 


c 


86078 


351 


M 


86344 


357 


C 


85415 


370 


c 


86079 


351 


M 


86353 


357 


C 


85420 


370 


c 


86140 


356 


c 


86359 


357 


C 


85421 


370 


c 


86147 


357 


c 


86360 


357 


c 


85441 


371 


c 


86155 


357 


c 


86376 


361 


c 


85445 


371 


c 


86156 


356 


c 


86378 


357 


C 


85460 


372 


c 


86157 


357 


c 


86382 


357 


C 


85461 


372 


c 


86160 


357 


C 


86384 


358 


C 


85475 


370 


c 


86161 


357 


c 


86403 


356 


C 


85520 


370 


c 


86162 


357 


c 


86406 


356 


C 


85525 


370 


c 


86171 


356 


c 


86421 


356 


C 


85530 


370 


c 


86185 


357 


c 


86422 


356 


c 


85535 


372 


c 


86215 


357 


C 


86430 


356 


C 


85540 


372 


c 


86225 


357 


c 


86431 


356 


c 


85547 


371 


c 


86226 


357 


c 


86485 


356 


c 


85549 


363 


c 


86235 


357 


c 


86490 


356 


c 


85555 


371 


c 


86243 


357 


c 


86510 


356 


c 


85557 


371 


c 


86255 


356 


c 


86580 


356 


c 


85575 


370 


c 


86256 


356 


c 


86585 


356 


c 


85576 


370 


c 


86277 


36! 


c 


86586 


356 


c 


85585 


371 


c 


86280 


357 


c 


86588 


375 


c 


85590 


372 


c 


86287 


362 


c 


86590 


356 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



167 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


86592 


356 


C 


86729 


357 


C 


86920 


355 


C 


86593 


356 


c 


86732 


357 


C 


86921 


355 


C 


86602 


357 


c 


86735 


356 


C 


86922 


355 


C 


86603 


357 


c 


86738 


357 


C 


86927 


355 


C 


86606 


357 


c 


86741 


357 


C 


86930 


355 


C 


86609 


358 


c 


86744 


357 


C 


86931 


355 


C 


86612 


357 


c 


86747 


357 


C 


86932 


355 


C 


86615 


357 


c 


86750 


357 


C 


86940 


357 


C 


86617 


359 


c 


86753 


356 


C 


86941 


357 


C 


86618 


357 


c 


86756 


357 


C 


86945 


355 


C 


86619 . 


357 


c 


86759 


357 


C 


86950 


355 


C 


86622 . 


357 


c 


86762 


357 


C 


86965 


355 


C 


86625 


357 


c 


86765 


357 


C 


86970 


355 


C 


86628 


358 


c 


86768 


357 


C 


86971 


355 


C 


86631 


358 


c 


86771 


357 


C 


86972 


355 


C 


86632 


358 


c 


86774 


357 


C 


86975 


355 


C 


86635 


357 


c 


86777 


357 


C 


86976 


355 


C 


86638 


357 


c 


86778 


357 


C 


86977 


355 


C 


86641 


357 


c 


86781 


357 


C 


86978 


355 


C 


86644 


357 


c 


86784 


357 


C 


86985 


355 


C 


86645 


357 


c 


86787 


357 


c 


86999 


357 


C 


86648 


357 


c 


86790 


356 


c 


87001 


359 


C 


86651 


357 


c 


86793 


357 


c 


87003 


359 


C 


86652 


357 


c 


86800 


361 


c 


87015 


358 


C 


86653 


357 


c 


86805 


355 


c 


87040 


359 


C 


86654 


357 


c 


86806 


355 


c 


87045 


359 


C 


86658 


357 


c 


86807 


355 


c 


87060 


358 


C 


86663 


357 


c 


86808 


355 


c 


87070 


358 


C 


86664 


357 


c 


86812 


355 


c 


87072 


358 


C 


86665 


357 


c 


86813 


355 


c 


87075 


359 


C 


86668 


357 


c 


86816 


355 


c 


87076 


359 


C 


86671 


356 


c 


86817 


355 


c 


87081 


358 


C 


86674 


356 


c 


86821 


355 


c 


87082 


358 


C 


86677 


357 


c 


86822 


355 


c 


87083 


358 


C 


86682 


356 


c 


86849 


356 


c 


87084 


358 


C 


86684 


356 


c 


86850 


357 


c 


87085 


358 


C 


86687 


356 


c 


86860 


357 


c 


87086 


358 


C 


86688 


356 


c 


86870 


357 


c 


87087 


358 


C 


86689 


357 


c 


86880 


356 


c 


87088 


358 


C 


86692 


356 


c 


86885 


356 


c 


87101 


358 


C 


86694 


357 


c 


86886 


356 


c 


87102 


358 


C 


86695 


357 


c 


86890 


355 


c 


87103 


359 


c 


86698 


357 


c 


86891 


355 


c 


87106 


358 


c 


86701 


356 


c 


86900 


355 


c 


87109 


359 


c 


86702 


356 


c 


86901 


355 


c 


87110 


358 


c 


86703 


356 


c 


86903 


355 


c 


87116 


359 


c 


86710 


356 


c 


86904 


355 


c 


87117 


359 


c 


86713 


357 


c 


86905 


355 


c 


87118 


359 


c 


86717 


357 


c 


86906 


355 


c 


87140 


359 


c 


86720 


357 


c 


86910 


355 


c 


87143 


359 


c 


86723 


357 


c 


86911 


355 


c 


87145 


359 


c 


86727 


357 


c 


86915 


355 


c 


87147 


358 


c 


168 














Final 


Report 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


87151 


359 


C 


88125 


350 


M 


88329 


351 


M 


87155 


359 


c 


88130 


350 


M 


88331 


351 


M 


87158 


359 


c 


88140 


350 


M 


88332 


351 


M 


87163 


358 


c 


88150 


353 


C 


88342 


351 


M 


87164 


359 


c 


88151 


353 


C 


88346 


351 


M 


87166 


359 


c 


88155 


353 


C 


88347 


351 


M 


87174 


359 


c 


88156 


353 


C 


88348 


352 


M 


87175 


358 


c 


88157 


353 


C 


88349 


352 


M 


87176 


359 


c 


88160 


351 


M 


88355 


352 


M 


87177 


358 


c 


88161 


351 


M 


88356 


352 


M 


87178 


359 


c 


88162 


351 


M 


88358 


352 


M 


87179 - 


357 


c 


88170 


002 


C 


88362 


352 


M 


87181 


358 


c 


88171 


002 


C 


88365 


352 


M 


87184 


358 


c 


88172 


351 


M 


88371 


351 


M 


87186 


358 


c 


88173 


351 


M 


88372 


351 


M 


87187 


359 


c 


88180 


351 


M 


88399 


350 


M 


87188 


358 


c 


88182 


351 


M 


89050 


350 


M 


87190 


359 


c 


88199 


350 


M 


89051 


350 


M 


87192 


359 


c 


88230 


352 


M 


89060 


350 


M 


87197 


359 


c 


88233 


352 


M 


89100 


115 


M 


87205 


358 


c 


88235 


352 


M 


89105 


115 


M 


87206 


358 


c 


88237 


352 


M 


89125 


350 


M 


87207 


358 


c 


88239 


352 


M 


89130 


115 


M 


87208 


358 


c 


88245 


352 


M 


89132 


115 


M 


87210 


358 


c 


88248 


352 


M 


89135 


115 


M 


87211 


358 


c 


88250 


352 


M 


89136 


115 


M 


87220 


358 


c 


88260 


352 


M 


89140 


115 


M 


87230 


359 


c 


88261 


352 


M 


89141 


115 


M 


87250 


359 


c 


88262 


352 


M 


89160 


350 


M 


87252 


359 


c 


88263 


352 


M 


89190 


350 


M 


87253 


359 


c 


88267 


352 


M 


89205 


350 


M 


87999 


358 


c 


88269 


352 


M 


89250 


354 


C 


88000 


994 


c 


88280 


352 


M 


89300 


350 


M 


88005 


994 


c 


88283 


352 


M 


89310 


350 


M 


88007 


994 


c 


88285 


352 


M 


89320 


350 


M 


88012 


994 


c 


88289 


352 


M 


89325 


350 


M 


88014 


994 


c 


88299 


352 


M 


89329 


350 


M 


88016 


994 


c 


88300 


350 


M 


89330 


350 


M 


88020 


994 


c 


88302 


351 


M 


89350 


350 


M 


88025 


994 


c 


88304 


351 


M 


89355 


350 


M 


88027 


994 


c 


88305 


351 


M 


89360 


350 


M 


88028 


994 


c 


88307 


352 


M 


89365 


350 


M 


88029 


994 


c 


88309 


352 


M 


89399 


350 


M 


88036 


994 


c 


88311 


350 


M 


90700 


330 


C 


88037 


994 


c 


88312 


351 


M 


90701 


330 


C 


88040 


994 


c 


88313 


350 


M 


90702 


330 


C 


88045 


994 


c 


88314 


35! 


M 


90703 


330 


C 


88099 


994 


c 


88318 


351 


M 


90704 


330 


C 


88104 


351 


M 


88319 


351 


M 


90705 


330 


C 


88106 


351 


M 


88321 


351 


M 


90706 


330 


C 


88107 


351 


M 


88323 


351 


M 


90707 


331 


C 


88108 


351 


M 


88325 


351 


M 


90708 


330 


C 



The Development of a Physician Prospective Payment System for Ambulatory Care 



169 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


90709 


330 


C 


90855 


423 


C 


92012 


207 


C 


90710 


330 


C 


90857 


295 


C 


92014 


207 


C 


90711 


330 


C 


90862 


423 


C 


92015 


421 


C 


90712 


331 


C 


90870 


182 


C 


92018 


207 


C 


90713 


331 


C 


90871 


182 


C 


92019 


207 


C 


90714 


330 


C 


90880 


423 


C 


92020 


208 


M 


90716 


331 


C 


90882 


344 


C 


92060 


208 


M 


90717 


331 


C 


90887 


344 


C 


92065 


208 


M 


90718 


330 


c 


90889 


344 


c 


92070 


209 


C 


90719 


330 


c 


90899 


423 


C 


92081 


208 


M 


90720 


. 331 


c 


90900 


315 


C 


92082 


208 


M 


90721 - 


" 332 


c 


90902 


315 


c 


92083 


208 


M 


90724 


330 


c 


90904 


315 


c 


92100 


205 


C 


90725 


330 


c 


90906 


315 


c 


92120 


205 


C 


90726 


332 


c 


90908 


315 


C 


92130 


205 


C 


90727 


332 


c 


90910 


315 


C 


92140 


208 


M 


90728 


332 


c 


90911 


315 


C 


92225 


208 


M 


90730 


330 


c 


90915 


315 


C 


92226 


208 


M 


90731 


331 


c 


90918 


995 


c 


92230 


205 


C 


90732 


330 


c 


90919 


995 


C 


92235 


206 


M 


90733 


331 


c 


90920 


995 


C 


92250 


205 


C 


90735 


332 


c 


90921 


995 


C 


92260 


205 


C 


90737 


331 


c 


90922 


995 


C 


92265 


205 


C 


90741 


331 


c 


90923 


995 


C 


92270 


206 


M 


90742 


332 


c 


90924 


995 


c 


92275 


206 


M 


90744 


331 


c 


90925 


995 


C 


92280 


190 


M 


90745 


331 


c 


90935 


145 


C 


92283 


208 


M 


90746 


331 


c 


90937 


145 


C 


92284 


208 


M 


90747 


331 


c 


90945 


146 


C 


92285 


208 


M 


90749 


330 


c 


90947 


146 


C 


92286 


206 


M 


90780 


094 


c 


90989 


995 


C 


92287 


206 


M 


90781 


094 


c 


90993 


995 


C 


92310 


209 


C 


90782 


327 


c 


90997 


145 


C 


92311 


209 


C 


90783 


091 


c 


90999 


146 


C 


92312 


209 


C 


90784 


091 


c 


91000 


115 


M 


92313 


209 


C 


90788 


327 


c 


91010 


115 


M 


92314 


209 


C 


90798 


094 


c 


91011 


115 


M 


92315 


209 


C 


90799 


088 


c 


91012 


115 


M 


92316 


209 


C 


90801 


423 


c 


91020 


115 


M 


92317 


209 


C 


90820 


423 


c 


91030 


115 


M 


92325 


209 


C 


90825 


344 


c 


91032 


115 


M 


92326 


209 


C 


90830 


307 


c 


91033 


115 


M 


92330 


209 


C 


90835 


423 


c 


91052 


115 


M 


92335 


209 


C 


90841 


423 


c 


91055 


115 


M 


92340 


210 


C 


90842 


423 


c 


91060 


115 


M 


92341 


210 


C 


90843 


423 


c 


91065 


363 


C 


92342 


210 


C 


90844 


423 


c 


91100 


115 


M 


92352 


210 


C 


90845 


423 


c 


91105 


115 


M 


92353 


210 


C 


90846 


294 


c 


91122 


115 


M 


92354 


209 


C 


90847 


294 


c 


91299 


115 


M 


92355 


209 


C 


90849 


295 


c 


92002 


207 


C 


92358 


209 


c 


90853 


295 


c 


92004 


207 


C 


92370 


210 


c 


170 














Final Report 



.»■ 



?1T 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


92371 


210 


C 


92576 


238 


C 


93042 


070 


P 


92390 


989 


C 


92577 


238 


C 


93201 


995 


C 


92391 


989 


c 


92578 


238 


C 


93202 


995 


C 


92392 


989 


c 


92579 


238 


C 


93204 


995 


C 


92393 


989 


c 


92580 


238 


C 


93205 


995 


C 


92395 


989 


c 


92582 


238 


C 


93208 


995 


c 


92396 


989 


c 


92583 


238 


C 


93209 


995 


C 


92499 


205 


c 


92584 


231 


M 


93210 


995 


M 


92502 


233 


c 


92585 


191 


M 


93220 


071 


M 


92504 


233 


c 


92587 


231 


M 


93221 


070 


T 


92506 


. 318 


c 


92588 


231 


M 


93222 


070 


P 


92507 . 


318 


c 


92589 


238 


C 


93224 


071 


M 


92508 


318 


c 


92590 


238 


C 


93225 


071 


T 


92510 


318 


c 


92591 


238 


C 


93226 


071 


T 


92511 


059 


c 


92592 


238 


c 


93227 


071 


P 


92512 


231 


M 


92593 


238 


c 


93230 


071 


M 


92516 


231 


M 


92594 


238 


c 


93231 


071 


M 


92520 


231 


M 


92595 


238 


c 


93232 


071 


T 


92525 


318 


C 


92596 


238 


c 


93233 


071 


P 


92526 


318 


C 


92597 


318 


c 


93235 


071 


M 


92531 


421 


c 


92598 


318 


c 


93236 


071 


T 


92532 


421 


c 


92599 


240 


c 


93237 


071 


P 


92533 


231 


M 


92950 


087 


c 


93255 


995 


M 


92534 


421 


c 


92953 


087 


c 


93268 


071 


M 


92541 


231 


M 


92960 


087 


c 


93270 


071 


T 


92542 


231 


M 


92970 


993 


c 


93271 


071 


T 


92543 


231 


M 


92971 


993 


c 


93272 


071 


P 


92544 


231 


M 


92975 


993 


c 


93278 


071 


M 


92545 


231 


M 


92977 


094 


c 


93280 


260 


M 


92546 


231 


M 


92980 


993 


c 


93307 


074 


M 


92547 


231 


M 


92981 


993 


c 


93308 


074 


M 


92551 


240 


C 


92982 


993 


c 


93312 


074 


M 


92552 


240 


C 


92984 


993 


c 


93313 


074 


P 


92553 


240 


C 


92986 


993 


c 


93314 


074 


P 


92555 


078 


C 


92987 


993 


c 


93320 


074 


M 


92556 


078 


C 


92990 


993 


c 


93321 


074 


M 


92557 


238 


C 


92992 


993 


c 


93325 


074 


M 


92559 


238 


C 


92993 


993 


c 


93350 


074 


M 


92560 


238 


C 


92995 


993 


c 


93501 


076 


M 


92561 


238 


C 


92996 


993 


c 


93503 


092 


C 


92562 


238 


C 


93000 


070 


M 


93505 


076 


M 


92563 


238 


C 


93005 


070 


T 


93510 


076 


M 


92564 


238 


C 


93010 


070 


p 


93511 


076 


M 


92565 


238 


C 


93012 


071 


T 


93514 


076 


M 


92567 


240 


C 


93014 


070 


P 


93524 


076 


M 


92568 


238 


C 


93015 


073 


M 


93526 


076 


M 


92569 


238 


C 


93016 


073 


P 


93527 


076 


M 


92571 


238 


C 


93017 


073 


T 


93528 


076 


M 


92572 


238 


C 


93018 


073 


P 


93529 


076 


M 


92573 


238 


C 


93024 


073 


M 


93536 


993 


C 


92574 


238 


c 


93040 


070 


M 


93539 


078 


C 


92575 


238 


C 


93041 


070 


T 


93540 


078 


C 



The Development of a Physician Prosfjective Payment System for Ambulatory Care 



171 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


93541 


078 


C 


93738 


340 


M 


94640 


063 


C 


93542 


078 


C 


93740 


072 


M 


94642 


063 


C 


93543 


078 


C 


93760 


072 


M 


94650 


063 


C 


93544 


078 


C 


93762 


071 


M 


94651 


063 


C 


93545 


078 


C 


93770 


421 


C 


94652 


993 


c 


93546 


076 


M 


93784 


071 


M 


94656 


993 


C 


93547 


076 


M 


93786 


072 


T 


94657 


063 


C 


93548 


076 


M 


93788 


071 


T 


94660 


063 


c 


93549 


076 


M 


93790 


071 


P 


94662 


063 


C 


93550 


076 


M 


93797 


088 


C 


94664 


063 


c 


93551 


. 078 


C 


93798 


088 


C 


94665 


063 


C 


93552 


. 076 


M 


93799 


072 


M 


94667 


063 


C 


93553 


076 


M 


93875 


274 


M 


94668 


063 


C 


93555 


270 


M 


93880 


274 


M 


94680 


056 


M 


93556 


270 


M 


93882 


274 


M 


94681 


056 


M 


93561 


092 


C 


93886 


274 


M 


94690 


055 


M 


93562 


092 


C 


93888 


274 


M 


94720 


056 


M 


93600 


075 


M 


93920 


072 


M 


94725 


056 


M 


93602 


075 


M 


93921 


072 


M 


94750 


057 


M 


93603 


075 


M 


93922 


072 


M 


94760 


055 


M 


93607 


075 


M 


93923 


072 


M 


94761 


055 


M 


93609 


075 


M 


93924 


072 


M 


94762 


055 


M 


93610 


075 


M 


93925 


274 


M 


94770 


055 


M 


93612 


075 


M 


93926 


274 


M 


94772 


057 


M 


93615 


075 


M 


93930 


274 


M 


94799 


055 


M 


93616 


075 


M 


93931 


274 


M 


95004 


328 


C 


93618 


075 


M 


93965 


072 


M 


95010 


328 


C 


93619 


075 


M 


93970 


274 


M 


95015 


328 


C 


93620 


075 


M 


93971 


274 


M 


95024 


328 


C 


93621 


075 


M 


93975 


274 


M 


95027 


328 


C 


93622 


075 


M 


93976 


274 


M 


95028 


328 


C 


93623 


075 


M 


93978 


274 


M 


95040 


328 


C 


93624 


075 


M 


93979 


274 


M 


95041 


328 


C 


93631 


993 


M 


93980 


274 


M 


95042 


328 


C 


93640 


075 


M 


93981 


274 


M 


95043 


328 


C 


93641 


075 


M 


93990 


274 


M 


95044 


328 


C 


93642 


075 


M 


94010 


055 


M 


95050 


328 


C 


93650 


075 


M 


94060 


055 


M 


95051 


328 


C 


93651 


075 


M 


94070 


057 


M 


95052 


328 


c 


93652 


075 


M 


94150 


055 


M 


95056 


328 


C 


93660 


075 


M 


94160 


055 


M 


95060 


328 


c 


93720 


072 


M 


94200 


055 


M 


95065 


328 


C 


93721 


072 


T 


94240 


056 


M 


95070 


057 


M 


93722 


072 


P 


94250 


055 


M 


95071 


057 


M 


93724 


075 


M 


94260 


056 


M 


95075 


115 


M 


93731 


340 


M 


94350 


056 


M 


95078 


328 


C 


93732 


340 


M 


94360 


055 


M 


95105 


344 


C 


93733 


340 


M 


94370 


056 


M 


95115 


329 


C 


93734 


340 


M 


94375 


056 


M 


95117 


329 


C 


93735 


340 


M 


94400 


055 


M 


95120 


329 


C 


93736 


340 


M 


94450 


055 


M 


95125 


329 


C 


93737 


340 


M 


94620 


055 


M 


95130 


329 


c 


172 














Final 


Report 



r^-trr^ 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


95131 


329 


C 


95872 


191 


M 


96542 


095 


C 


95132 


329 


C 


95875 


191 


M 


96545 


421 


C 


95133 


329 


C 


95880 


318 


C 


96549 


097 


C 


95134 


329 


C 


95881 


307 


C 


96900 


001 


C 


95135 


330 


C 


95882 


307 


C 


96910 


001 


C 


95140 


329 


C 


95883 


307 


C 


96912 


001 


C 


95144 


329 


C 


95900 


190 


M 


96913 


001 


C 


95145 


329 


C 


95903 


190 


M 


96999 


001 


C 


95146 


329 


C 


95904 


190 


M 


97010 


317 


C 


95147 


329 


C 


95920 


993 


M 


97012 


317 


C 


95148 


. 329 


C 


95925 


191 


M 


97014 


317 


C 


95149 


- 330 


C 


95926 


190 


M 


97016 


317 


C 


95150 


329 


C 


95927 


190 


M 


97018 


317 


C 


95155 


329 


C 


95930 


190 


M 


97020 


317 


C 


95165 


329 


C 


95933 


190 


M 


97022 


317 


C 


95170 


330 


C 


95934 


190 


M 


97024 


317 


c 


95180 


328 


C 


95935 


190 


M 


97026 


317 


c 


95199 


328 


C 


95936 


190 


M 


97028 


317 


c 


95805 


180 


M 


95937 


190 


M 


97032 


317 


c 


95807 


180 


M 


95950 


180 


M 


97033 


317 


c 


95808 


180 


M 


95951 


180 


M 


97034 


317 


c 


95810 


180 


M 


95953 


180 


M 


97035 


317 


c 


95812 


180 


M 


95954 


181 


M 


97036 


317 


c 


95813 


180 


M 


95955 


993 


M 


97039 


317 


c 


95816 


181 


M 


95956 


180 


M 


97110 


317 


c 


95817 


181 


M 


95957 


340 


P 


97112 


317 


c 


95819 


181 


M 


95958 


180 


M 


97113 


317 


c 


95821 


181 


M 


95961 


993 


M 


97114 


317 


c 


95822 


181 


M 


95962 


993 


M 


97116 


317 


c 


95823 


181 


M 


95999 


181 


M 


97118 


317 


c 


95824 


181 


M 


96100 


307 


C 


97120 


317 


c 


95826 


181 


M 


96105 


307 


C 


97122 


317 


c 


95827 


180 


M 


96110 


307 


C 


97124 


317 


c 


95828 


180 


M 


96111 


307 


C 


97126 


317 


c 


95829 


993 


M 


96115 


307 


C 


97128 


317 


c 


95830 


233 


C 


96117 


307 


C 


97139 


317 


c 


95831 


421 


C 


96400 


097 


c 


97145 


317 


c 


95832 


421 


C 


96405 


097 


c 


97150 


317 


c 


95833 


421 


C 


96406 


097 


c 


97220 


317 


c 


95834 


421 


C 


96408 


096 


c 


97221 


317 


c 


95842 


190 


M 


96410 


096 


c 


97240 


317 


c 


95851 


421 


C 


96412 


096 


c 


97241 


317 


c 


95852 


421 


C 


96414 


095 


c 


97250 


319 


c 


95857 


190 


M 


96420 


096 


c 


97260 


319 


c 


95858 


191 


M 


96422 


096 


c 


97261 


319 


c 


95860 


191 


M 


96423 


096 


c 


97265 


317 


c 


95861 


191 


M 


96425 


095 


c 


97500 


317 


c 


95863 


191 


M 


96440 


095 


c 


97501 


317 


c 


95864 


191 


M 


96445 


095 


c 


97520 


317 


c 


95867 


190 


M 


96450 


095 


c 


97521 


317 


c 


95868 


191 


M 


96520 


096 


c 


97530 


317 


c 


95869 


190 


M 


96530 


096 


c 


97531 


317 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



173 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


97535 


316 


C 


99191 


993 


C 


99295 


993 


C 


97537 


316 


C 


99192 


993 


C 


99296 


993 


C 


97540 


316 


C 


99195 


099 


C 


99297 


993 


C 


97541 


316 


C 


99199 


995 


C 


99301 


995 


c 


97542 


316 


C 


99201 


422 


C 


99302 


995 


c 


97545 


317 


C 


99202 


422 


C 


99303 


995 


c 


97546 


317 


C 


99203 


422 


C 


99311 


995 


c 


97700 


317 


C 


99204 


422 


C 


99312 


995 


c 


97701 


317 


C 


99205 


422 


c 


99313 


995 


c 


97703 


317 


C 


99211 


422 


c 


99321 


342 


c 


97720 


317 


C 


99212 


422 


c 


99322 


342 


c 


97721 - 


317 


C 


99213 


422 


c 


99323 


342 


c 


97750 


317 


C 


99214 


422 


c 


99331 


342 


c 


97752 


317 


C 


99215 


422 


c 


99332 


342 


c 


97770 


316 


C 


99217 


422 


c 


99333 


342 


c 


97799 


317 


C 


99218 


422 


c 


99341 


342 


c 


98925 


319 


c 


99219 


422 


c 


99342 


342 


c 


98926 


319 


c 


99220 


422 


c 


99343 


342 


c 


98927 


319 


c 


99221 


995 


c 


99351 


342 


c 


98928 


319 


c 


99777 


995 


c 


99352 


342 


c 


98929 


319 


c 


99223 


995 


c 


99353 


342 


c 


99000 


995 


c 


99231 


995 


c 


99354 


422 


c 


99001 


421 


c 


99232 


995 


c 


99355 


422 


c 


99002 


995 


c 


99233 


995 


c 


99356 


993 


c 


99024 


421 


c 


99238 


995 


c 


99357 


993 


c 


99025 


422 


c 


99239 


995 


c 


99358 


422 


c 


99050 


995 


c 


99241 


422 


c 


99359 


422 


c 


99052 


995 


c 


99242 


422 


c 


99360 


422 


c 


99054 


995 


c 


99243 


422 


c 


99361 


344 


c 


99056 


995 


c 


99244 


422 


c 


99362 


344 


c 


99058 


422 


c 


99245 


422 


c 


99371 


344 


c 


99070 


403 


c 


99251 


995 


c 


99372 


344 


c 


99071 


995 


c 


99252 


995 


c 


99373 


344 


c 


99075 


995 


c 


99253 


995 


c 


99375 


343 


c 


99078 


344 


c 


99254 


995 


c 


99376 


343 


c 


99080 


995 


c 


99255 


995 


c 


99381 


422 


c 


99082 


995 


c 


99261 


995 


c 


99382 


422 


c 


99090 


995 


c 


99262 


995 


c 


99383 


422 


c 


99100 


335 


c 


99263 


995 


c 


99384 


422 


c 


99116 


993 


c 


99271 


422 


c 


99385 


422 


c 


99135 


993 


c 


99272 


422 


c 


99386 


422 


c 


99140 


335 


c 


99273 


422 


c 


99387 


422 


c 


99150 


422 


c 


99274 


422 


c 


99391 


422 


c 


99151 


422 


c 


99275 


422 


c 


99392 


422 


c 


99175 


421 


c 


99281 


422 


c 


99393 


422 


c 


99178 


344 


c 


99282 


422 


c 


99394 


422 


c 


99180 


252 


c 


99283 


422 


c 


99395 


422 


c 


99182 


252 


c 


99284 


422 


c 


99396 


422 


c 


99183 


252 


c 


99285 


422 


c 


99397 


422 


c 


99185 


993 


c 


99288 


344 


c 


99401 


422 


c 


99186 


993 


c 


99291 


422 


c 


99402 


422 


c 


99190 


993 


c 


99292 


422 


c 


99403 


422 


c 


174 














Final 


Report 



ifAs*;' 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


99404 


422 


C 


A0328 


995 


C 


A4250 


403 


C 


99411 


422 


c 


A0330 


995 


C 


A4253 


403 


C 


99412 


422 


c 


A0340 


995 


c 


A4254 


403 


C 


99420 


422 


c 


A0342 


995 


C 


A4256 


403 


C 


99429 


422 


c 


A0344 


995 


C 


A4258 


403 


C 


99431 


422 


c 


A0346 


995 


C 


A4259 


403 


C 


99432 


422 


c 


A0348 


995 


C 


A4260 


403 


C 


99433 


995 


c 


A0350 


995 


C 


A4262 


403 


C 


99435 


995 


c 


A0360 


995 


C 


A4263 


403 


C 


99440 


087 


c 


A0362 


995 


C 


A4265 


403 


C 


99450 - 


422 


c 


A0364 


995 


C 


A4270 


403 


C 


99455 - 


422 


c 


A0366 


995 


C 


A4300 


403 


C 


99456 


422 


c 


A0368 


995 


C 


A4301 


403 


C 


99499 


422 


c 


A0370 


995 


C 


A4305 


403 


C 


AOOlO 


995 


c 


A0380 


995 


C 


A4306 


403 


C 


A0020 


995 


c 


A0382 


995 


C 


A4310 


403 


C 


A0021 


995 


c 


A0384 


995 


C 


A4311 


403 


C 


A0030 


995 


c 


A0390 


995 


C 


A4312 


403 


C 


A0040 


995 


c 


A0392 


995 


C 


A4313 


403 


C 


A0050 


995 


c 


A0394 


995 


C 


A4314 


403 


C 


A0060 


995 


c 


A0396 


995 


C 


A4315 


403 


C 


A0070 


995 


c 


A0398 


995 


C 


A4316 


403 


C 


A0080 


995 


c 


A0420 


995 


C 


A4320 


403 


C 


A0090 


995 


c 


A0422 


995 


C 


A4322 


403 


C 


AOlOO 


995 


c 


A0424 


995 


C 


A4323 


403 


C 


AOllO 


995 


c 


A0888 


995 


C 


A4326 


403 


C 


A0120 


995 


c 


A0999 


995 


C 


A4327 


403 


C 


A0130 


995 


c 


A2000 


319 


C 


A4328 


403 


C 


A0140 


995 


c 


A4190 


403 


C 


A4329 


403 


C 


A0150 


995 


c 


A4200 


403 


c 


A4330 


403 


c 


A0160 


995 


c 


A4202 


403 


C 


A4335 


403 


c 


A0170 


995 


c 


A4203 


403 


C 


A4338 


403 


c 


A0180 


995 


c 


A4204 


403 


C 


A4340 


403 


c 


A0190 


995 


c 


A4205 


403 


C 


A4344 


403 


c 


A0200 


995 


c 


A4206 


403 


C 


A4346 


403 


c 


A0210 


995 


c 


A4207 


403 


C 


A4347 


403 


c 


A0215 


995 


c 


A4208 


403 


C 


A4351 


403 


c 


A0220 


995 


c 


A4209 


403 


C 


A4352 


403 


c 


A0221 


995 


c 


A4210 


403 


C 


A4354 


403 


c 


A0222 


995 


c 


A4211 


403 


C 


A4355 


403 


c 


A0223 


995 


c 


A4212 


403 


C 


A4356 


403 


c 


A0225 


995 


c 


A4213 


403 


C 


A4357 


403 


c 


A0300 


995 


c 


A4214 


403 


C 


A4358 


403 


c 


A0302 


995 


c 


A4215 


403 


C 


A4359 


403 


c 


A0304 


995 


c 


A4220 


403 


c 


A4361 


403 


c 


A0306 


995 


c 


A4230 


403 


C 


A4362 


403 


c 


A0308 


995 


c 


A4231 


403 


C 


A4363 


403 


c 


A0310 


995 


c 


A4232 


403 


C 


A4364 


403 


c 


A0320 


995 


c 


A4244 


403 


C 


A4367 


403 


c 


A0322 


995 


c 


A4245 


403 


C 


A4397 


403 


c 


A0324 


995 


c 


A4246 


403 


c 


A4398 


403 


c 


A0326 


995 


c 


A4247 


403 


C 


A4399 


403 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



175 



APPENDIX E 


















Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


A4400 


403 


C 


A4640 


403 


C 


A4921 


401 


C 


A4402 


403 


C 


A4641 


402 


C 


A4927 


401 


C 


A4404 


403 


C 


A4642 


402 


C 


A5051 


403 


C 


A4421 


403 


C 


A4643 


402 


C 


A5052 


403 


C 


A4454 


403 


C 


A4644 


402 


C 


A5053 


403 


C 


A4455 


403 


C 


A4645 


402 


C 


A5054 


403 


C 


A4460 


403 


C 


A4646 


402 


C 


A5055 


403 


C 


A4465 


403 


C 


A4647 


402 


C 


A5061 


403 


C 


A4470 


403 


C 


A4648 


402 


C 


A5062 


403 


C 


A4480 


403 


C 


A4649 


402 


C 


A5063 


403 


C 


A4490 


403 


C 


A4650 


401 


C 


A5064 


403 


C 


A4495 


- 403 


C 


A4655 


401 


C 


A5065 


403 


C 


A4500 


403 


C 


A4660 


401 


C 


A5071 


403 


C 


A4510 


403 


C 


A4663 


401 


C 


A5072 


403 


C 


A4550 


403 


C 


A4670 


401 


C 


A5073 


403 


C 


A4554 


403 


c 


A4680 


401 


C 


A5074 


403 


C 


A4556 


403 


c 


A4690 


401 


C 


A5075 


403 


C 


A4557 


403 


c 


A4700 


401 


C 


A5081 


403 


C 


A4558 


403 


c 


A4705 


401 


C 


A5082 


403 


C 


A4560 


403 


c 


A4712 


401 


C 


A5093 


403 


C 


A4565 


403 


c 


A4714 


401 


C 


A5102 


403 


C 


A4570 


403 


c 


A4730 


401 


C 


A5105 


403 


c 


A4572 


403 


c 


A4735 


401 


C 


A5112 


403 


C 


A4575 


403 


c 


A4740 


401 


C 


A5113 


403 


c 


A4580 


403 


c 


A4750 


401 


C 


A5114 


403 


C 


A4581 


403 


c 


A4755 


401 


c 


A5119 


403 


C 


A4590 


403 


c 


A4760 


401 


C 


A5121 


403 


C 


A4595 


403 


c 


A4765 


401 


C 


A5122 


403 


C 


A4610 


403 


c 


A4770 


401 


C 


A5123 


403 


c 


A4611 


403 


c 


A4771 


401 


c 


A5126 


403 


C 


A4612 


403 


c 


A4772 


401 


C 


A5131 


403 


C 


A4613 


403 


c 


A4773 


401 


c 


A5149 


403 


C 


A4615 


403 


c 


A4774 


401 


C 


A5500 


989 


C 


A4616 


403 


c 


A4780 


401 


c 


A5501 


989 


C 


A4617 


403 


c 


A4790 


401 


c 


A5502 


989 


C 


A4618 


403 


c 


A4800 


401 


C 


A5503 


989 


C 


A4619 


403 


c 


A4820 


401 


C 


A5504 


989 


C 


A4620 


403 


c 


A4850 


401 


C 


A5505 


989 


C 


A4621 


403 


c 


A4860 


401 


c 


A5506 


989 


C 


A4622 


403 


c 


A4870 


401 


C 


A5507 


989 


C 


A4623 


403 


c 


A4880 


401 


c 


A6020 


403 


C 


A4624 


403 


c 


A4890 


401 


C 


A9150 


995 


C 


A4625 


403 


c 


A4900 


401 


c 


A9160 


995 


C 


A4626 


403 


c 


A4901 


401 


C 


A9170 


995 


c 


A4627 


403 


c 


A4905 


401 


C 


A9180 


995 


C 


. A4628 


403 


c 


A4910 


401 


C 


A9I90 


995 


C 


A4629 


403 


c 


A4912 


401 


C 


A9270 


995 


c 


A4630 


403 


c 


A4913 


401 


c 


A9290 


995 


C 


A4631 


403 


c 


A4914 


401 


c 


A9300 


995 


C 


A4635 


403 


c 


A49I8 


401 


c 


A9500 


402 


c 


A4636 


403 


c 


A49I9 


401 


c 


A9505 


402 


c 


A4637 


403 


c 


A4920 


401 


c 


B4034 


403 


c 


176 














Final 


Report 



■".i-K*; ■ 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


B4035 


403 


C 


D0272 


765 


C 


D2410 


754 


C 


B4036 


403 


C 


D0274 


765 


C 


D2420 


754 


C 


B4081 


403 


C 


D0290 


765 


c 


D2430 


754 


C 


B4082 


403 


C 


D0310 


765 


c 


D2510 


754 


C 


B4083 


403 


C 


D0320 


765 


c 


D2520 


754 


C 


B4084 


403 


C 


D0321 


765 


c 


D2530 


754 


C 


B4085 


403 


C 


D0322 


765 


c 


D2540 


754 


C 


B4150 


396 


C 


D0330 


765 


c 


D2543 


754 


C 


B4151 


396 


C 


D0340 


765 


c 


D2544 


754 


C 


B4152 


396 


C 


D0415 


358 


c 


D2610 


754 


C 


B4153 


. 396 


C 


D0425 


763 


c 


D2620 


754 


C 


B4154 . 


396 


C 


D0460 


765 


c 


D2630 


754 


C 


B4155 


396 


C 


D0470 


765 


c 


D2640 


754 


C 


B4156 


396 


C 


D0471 


765 


c 


D2642 


754 


C 


B4164 


396 


C 


D0501 


765 


c 


D2643 


754 


C 


B4168 


396 


C 


D0502 


765 


c 


D2644 


754 


C 


B4172 


396 


C 


D0999 


765 


c 


D2650 


754 


C 


B4176 


396 


C 


DlllO 


751 


c 


D2651 


754 


C 


B4I78 


396 


C 


D1120 


751 


c 


D2652 


754 


C 


B4180 


396 


C 


D12G1 


751 


c 


D2660 


754 


C 


B4184 


396 


C 


D1203 


751 


c 


D2662 


754 


C 


B4186 


396 


C 


D1204 


751 


c 


D2663 


754 


C 


B4189 


396 


C 


D1205 


751 


c 


D2664 


754 


C 


B4193 


396 


c 


D1310 


751 


c 


D2710 


754 


C 


B4197 


396 


c 


D1320 


751 


c 


D2720 


754 


C 


B4199 


396 


c 


D1330 


751 


c 


D2721 


754 


c 


B4216 


396 


c 


D1351 


751 


c 


D2722 


754 


G 


B4220 


396 


c 


D1510 


765 


c 


D2740 


754 


C 


B4222 


396 


c 


D1515 


765 


c 


D2750 


754 


C 


B4224 


396 


c 


D1520 


765 


c 


D2751 


754 


C 


B5000 


396 


c 


D1525 


765 


c 


D2752 


754 


C 


B5100 


396 


c 


D1550 


765 


c 


D2790 


754 


C 


B5200 


396 


c 


D2110 


753 


c 


D2791 


754 


C 


B9000 


989 


c 


D2120 


753 


c 


D2792 


754 


C 


B9002 


989 


c 


D2130 


753 


c 


D2810 


754 


C 


B9004 


989 


c 


D2131 


753 


c 


D2910 


754 


C 


B9006 


989 


c 


D2140 


753 


c 


D2920 


754 


C 


B9998 


989 


c 


D2150 


753 


c 


D2930 


754 


C 


B9999 


989 


c 


D2160 


753 


c 


D2931 


754 


C 


DOllO 


750 


c 


D2161 


753 


c 


D2932 


754 


C 


DO 120 


750 


c 


D2210 


753 


c 


D2933 


754 


c 


D0130 


750 


c 


D2330 


753 


c 


D2940 


754 


c 


DO 140 


750 


c 


D2331 


753 


c 


D2950 


754 


C 


DO 150 


750 


c 


D2332 


753 


c 


D2951 


754 


c 


DO 160 


750 


c 


D2335 


753 


c 


D2952 


754 


c 


D0210 


765 


c 


D2336 


753 


c 


D2954 


754 


C 


D0220 


765 


c 


D2380 


753 


c 


D2955 


754 


C 


D0230 


765 


c 


D2381 


753 


c 


D2960 


754 


C 


D0240 


765 


c 


D2382 


753 


c 


D2961 


754 


c 


D0250 


765 


c 


D2385 


753 


c 


D2962 


754 


c 


D0260 


765 


c 


D2386 


753 


c 


D2970 


754 


c 


D0270 


765 


c 


D2387 


753 


c 


D2980 


754 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



177 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


D2999 


753 


C 


D4910 


756 


C 


D5919 


759 


C 


D3110 


755 


C 


D4920 


756 


C 


D5922 


759 


C 


D3120 


755 


c 


D4999 


756 


C 


D5923 


759 


C 


D3220 


755 


c 


D5110 


758 


c 


D5924 


759 


C 


D3230 


755 


c 


D5120 


758 


C 


D5925 


759 


C 


D3240 


755 


c 


D5130 


758 


C 


D5926 


759 


C 


D3310 


755 


c 


D5140 


758 


c 


D5927 


759 


C 


D3320 


755 


c 


D5211 


758 


c 


D5928 


759 


C 


D3330 


755 


c 


D5212 


758 


C 


D5929 


759 


C 


D3346 


755 


c 


D5213 


758 


C 


D5931 


759 


C 


D3347 


. 755 


c 


D5214 


758 


C 


D5932 


759 


C 


D3348 . 


755 


c 


D5281 


758 


C 


D5933 


759 


C 


D3351 


755 


c 


D5410 


757 


c 


D5934 


759 


C 


D3352 


755 


c 


D5411 


757 


C 


D5935 


759 


C 


D3353 


755 


c 


D5421 


757 


C 


D5936 


759 


C 


D3410 


755 


c 


D5422 


757 


C 


D5937 


759 


C 


D3421 


755 


c 


D5510 


757 


C 


D5951 


759 


C 


D3425 


755 


c 


D5520 


757 


C 


D5952 


759 


C 


D3426 


755 


c 


D5610 


757 


c 


D5953 


759 


C 


D3430 


755 


c 


D5620 


757 


C 


D5954 


759 


C 


D3450 


755 


c 


D5630 


757 


C 


D5955 


759 


C 


D3460 


755 


c 


D5640 


757 


C 


D5958 


759 


C 


D3470 


755 


c 


D5650 


757 


C 


D5959 


759 


C 


D3910 


755 


c 


D5660 


757 


C 


D5960 


759 


C 


D3920 


755 


c 


D5710 


757 


C 


D5982 


759 


C 


D3950 


755 


c 


D57I1 


757 


C 


D5983 


759 


C 


D3960 


755 


c 


D5720 


757 


C 


D5984 


759 


C 


D3999 


755 


c 


D5721 


757 


C 


D5985 


759 


C 


D4210 


756 


c 


D5730 


757 


c 


D5986 


759 


C 


D4211 


756 


c 


D5731 


757 


C 


D5987 


759 


C 


D4220 


756 


c 


D5740 


757 


C 


D5988 


759 


C 


D4240 


756 


c 


D5741 


757 


C 


D5999 


759 


C 


D4249 


756 


c 


D5750 


757 


C 


D6010 


761 


C 


D4250 


756 


c 


D5751 


757 


C 


D6020 


761 


C 


D4260 


756 


c 


D5760 


757 


C 


D6030 


761 


C 


D4261 


756 


c 


D5761 


757 


C 


D6040 


761 


c 


D4262 


756 


c 


D5810 


757 


C 


D6050 


761 


c 


D4263 


756 


c 


D5811 


757 


C 


D6055 


761 


c 


D4264 


756 


c 


D5820 


757 


C 


D6080 


761 


c 


D4266 


756 


c 


D5821 


757 


C 


D6090 


761 


c 


D4267 


756 


c 


D5850 


757 


C 


D6095 


761 


c 


D4268 


756 


c 


D5851 


757 


c 


D6100 


761 


c 


D4270 


756 


c 


D5860 


757 


C 


D6199 


761 


c 


D4271 


756 


c 


D5861 


757 


c 


D6210 


761 


c 


D4273 


756 


c 


D5862 


757 


C 


D621I 


761 


c 


D4274 


756 


c 


D5899 


757 


c 


D6212 


761 


c 


D4320 


756 


c 


D5911 


759 


C 


D6240 


761 


c 


D4321 


756 


c 


D5912 


759 


C 


D6241 


761 


c 


D4341 


756 


c 


D59I3 


759 


C 


D6242 


761 


c 


D4345 


756 


c 


D5914 


759 


C 


D6250 


761 


c 


D4355 


756 


c 


D5915 


759 


C 


D6251 


761 


c 


D4381 


756 


c 


D5916 


759 


C 


D6252 


761 


c 


178 














Final 


Report 



-%!**' 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


D6520 


761 


C 


D7430 


760 


C 


D7880 


760 


C 


D6530 


761 


C 


D7431 


760 


C 


D7899 


760 


C 


D6540 


761 


C 


D7440 


760 


C 


D7910 


760 


C 


D6543 


761 


C 


D7441 


760 


C 


D79I1 


760 


C 


D6544 


761 


C 


D7450 


760 


C 


D7912 


760 


C 


D6545 


761 


C 


D7451 


760 


C 


D7920 


760 


C 


D6720 


761 


C 


D7460 


760 


C 


D7940 


760 


C 


D6721 


761 


C 


D7461 


760 


c 


D7941 


760 


c 


D6722 


761 


C 


D7465 


760 


c 


D7942 


761 


C 


D6750 


761 


C 


D7470 


760 


c 


D7943 


761 


C 


D6751 


. 761 


C 


D7480 


760 


c 


D7944 


761 


C 


D6752 - 


■ 761 


C 


D7490 


760 


c 


D7945 


761 


C 


D6780 


761 


c 


D7510 


760 


c 


D7946 


761 


C 


D6790 


761 


c 


D7520 


760 


c 


D7947 


761 


C 


D6791 


761 


c 


D7530 


760 


c 


D7948 


761 


C 


D6792 


761 


c 


D7540 


760 


c 


D7949 


761 


C 


D6920 


761 


c 


D7550 


761 


c 


D7950 


761 


C 


D6930 


761 


c 


D7560 


761 


c 


D7955 


761 


C 


D6940 


761 


c 


D7610 


761 


c 


D7960 


760 


C 


D6950 


761 


c 


D7620 


760 


c 


D7970 


760 


C 


D6970 


761 


c 


D7630 


761 


c 


D7971 


760 


C 


D6971 


761 


c 


D7640 


760 


c 


D7980 


760 


C 


D6972 


761 


c 


D7650 


761 


c 


D7981 


760 


C 


D6973 


761 


c 


D7660 


760 


c 


D7982 


760 


C 


D6975 


761 


c 


D7670 


761 


c 


D7983 


761 


C 


D6980 


761 


c 


D7680 


761 


c 


D7990 


761 


C 


D6999 


760 


c 


D7710 


761 


c 


D7991 


761 


C 


D7110 


760 


c 


D7720 


761 


c 


D7993 


761 


C 


D7120 


760 


c 


D7730 


761 


c 


D7994 


761 


C 


D7130 


760 


c 


D7740 


760 


c 


D7995 


761 


C 


D7210 


760 


c 


D7750 


761 


c 


D7996 


760 


C 


D7220 


760 


c 


D7760 


760 


c 


D7999 


760 


C 


D7230 


760 


c 


D7770 


761 


c 


D8010 


763 


C 


D7240 


760 


c 


D7780 


761 


c 


D8020 


763 


c 


D7241 


760 


c 


D7810 


761 


c 


D8030 


763 


C 


D7250 


760 


c 


D7820 


760 


c 


D8040 


763 


c 


D7260 


761 


c 


D7830 


761 


c 


D8050 


763 


c 


D7270 


761 


c 


D7840 


761 


c 


D8060 


763 


c 


D7271 


761 


c 


D7850 


761 


c 


D8070 


763 


c 


D7272 


761 


c 


D7852 


761 


c 


D8080 


763 


c 


D7280 


761 


c 


D7854 


761 


c 


D8090 


763 


c 


D7281 


761 


c 


D7856 


761 


c 


D8110 


762 


c 


D7285 


761 


c 


D7858 


761 


c 


D8120 


762 


c 


D7286 


761 


c 


D7860 


761 


c 


D8210 


762 


c 


D7290 


761 


c 


D7865 


760 


c 


D8220 


762 


c 


D7291 


761 


c 


D7870 


760 


c 


D8360 


762 


c 


D7310 


761 


c 


D7872 


760 


c 


D8370 


762 


c 


D7320 


761 


c 


D7873 


760 


c 


D8460 


762 


c 


D7340 


761 


c 


D7874 


760 


c 


D8470 


762 


c 


D7350 


761 


c 


D7875 


760 


c 


D8480 


762 


c 


D7410 


760 


c 


D7876 


760 


c 


D8560 


762 


c 


D7420 


760 


c 


D7877 


760 


c 


D8570 


762 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



179 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


D8580 


762 


C 


E0155 


989 


C 


E0246 


989 


C 


D8650 


762 


C 


E0156 


989 


C 


E0249 


989 


C 


D8660 


762 


c 


E0157 


989 


C 


E0250 


989 


C 


D8670 


762 


c 


E0158 


989 


c 


E0251 


989 


C 


D8680 


762 


c 


E0160 


989 


c 


E0255 


989 


C 


D8690 


762 


c 


E0161 


989 


c 


E0256 


989 


C 


D8750 


762 


c 


E0162 


989 


c 


E0260 


989 


C 


D8999 


762 


c 


E0163 


989 


c 


E0261 


989 


C 


D9110 


767 


c 


E0164 


989 


C 


E0265 


989 


C 


D9210 


767 


c 


E0165 


989 


c 


E0266 


989 


C 


D9211 - 


767 


c 


E0166 


989 


C 


E0270 


989 


C 


D9212 - 


767 


c 


E0167 


989 


C 


E0271 


989 


C 


D9215 


767 


c 


E0175 


989 


c 


E0272 


989 


C 


D9220 


767 


c 


E0176 


989 


c 


E0273 


989 


C 


D9221 


767 


c 


E0I77 


989 


C 


E0274 


989 


C 


D9230 


767 


c 


E0178 


989 


C 


E0275 


989 


C 


D9240 


767 


c 


E0179 


989 


C 


E0276 


989 


C 


D9310 


764 


c 


E0180 


989 


C 


E0277 


989 


C 


D9410 


764 


c 


E018I 


989 


C 


E0280 


989 


C 


D9420 


764 


c 


E0182 


989 


C 


E0290 


989 


C 


D9430 


764 


c 


E0184 


989 


C 


E0291 


989 


C 


D9440 


764 


c 


E0185 


989 


c 


E0292 


989 


C 


D9610 


765 


c 


E0186 


989 


C 


E0293 


989 


C 


D9630 


765 


c 


E0187 


989 


C 


E0294 


989 


C 


D9910 


765 


c 


E0188 


989 


C 


E0295 


989 


c 


D9920 


765 


c 


E0189 


989 


C 


E0296 


989 


c 


D9930 


765 


c 


E0191 


989 


C 


E0297 


989 


c 


D9940 


765 


c 


E0192 


989 


C 


E0305 


989 


c 


D9941 


765 


c 


E0193 


989 


C 


E0310 


989 


c 


D9950 


765 


c 


E0194 


989 


c 


E0315 


989 


c 


D9951 


765 


c 


E0196 


989 


C 


E0325 


989 


c 


D9952 


765 


c 


E0197 


989 


C 


E0326 


989 


c 


D9970 


765 


c 


E0198 


989 


C 


E0350 


989 


c 


D9999 


765 


c 


E0199 


989 


c 


E0352 


989 


c 


EOlOO 


989 


c 


E0200 


989 


c 


E0424 


989 


c 


E0105 


989 


c 


E0202 


989 


C 


E0425 


989 


c 


EOllO 


989 


c 


E0205 


989 


C 


E0430 


989 


c 


EOlll 


989 


c 


E0210 


989 


C 


E0431 


989 


c 


E0112 


989 


c 


E0215 


989 


C 


E0434 


989 


c 


E01I3 


989 


c 


E0220 


989 


C 


E0435 


989 


c 


E0114 


989 


c 


E0225 


989 


c 


E0439 


989 


c 


E0116 


989 


c 


E0230 


989 


c 


E0440 


989 


c 


E0130 


989 


c 


E0235 


989 


c 


E0441 


989 


c 


E0135 


989 


c 


E0236 


989 


c 


E0442 


989 


c 


E0141 


989 


c 


E0237 


989 


c 


E0443 


989 


c 


E0142 


989 


c 


E0238 


989 


c 


E0444 


989 


c 


E0143 


989 


c 


E0239 


989 


c 


E0450 


989 


c 


E0145 


989 


c 


E0241 


989 


c 


E0452 


989 


c 


E0146 


989 


c 


E0242 


989 


c 


E0453 


989 


c 


E0147 


989 


c 


E0243 


989 


c 


E0455 


989 


c 


E0153 


989 


c 


E0244 


989 


c 


E0457 


989 


c 


E0154 


989 


c 


E0245 


989 


C 


E0459 


989 


c 


180 














Final 


Report 



Ilvii 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


E0460 


989 


C 


E0747 


989 


C 


E0973 


989 


C 


E0462 


989 


C 


E0748 


989 


C 


E0974 


989 


C 


E0480 


989 


c 


E0749 


989 


C 


E0975 


989 


C 


E0500 


989 


c 


E0750 


989 


c 


E0976 


989 


c 


E0550 


989 


c 


E0751 


989 


C 


E0977 


989 


c 


E0555 


989 


c 


E0753 


989 


C 


E0978 


989 


c 


E0560 


989 


c 


E0755 


989 


C 


E0979 


989 


c 


E0565 


989 


c 


E0776 


989 


c 


E0980 


989 


c 


E0570 


989 


c 


E0781 


989 


C 


E0990 


989 


c 


E0575 


989 


c 


E0782 


989 


c 


E0991 


989 


c 


E0580 


989 


c 


E0783 


989 


c 


E0992 


989 


c 


E0585 - 


989 


c 


E0784 


989 


C 


E0993 


989 


c 


E0600 


989 


c 


E0791 


989 


c 


E0994 


989 


c 


E0601 


989 


c 


E0840 


989 


c 


E0995 


989 


c 


E0605 


989 


c 


E0850 


989 


c 


E0996 


989 


c 


E0606 


989 


c 


E0860 


989 


c 


E0997 


989 


c 


E0607 


989 


c 


E0870 


989 


c 


E0998 


989 


c 


E0608 


989 


c 


E0880 


989 


C 


E0999 


989 


c 


E0609 


989 


c 


E0890 


989 


c 


ElOOO 


989 


c 


E0610 


989 


c 


E0900 


989 


C 


ElOOl 


989 


c 


E0615 


989 


c 


E0910 


989 


c 


E1031 


989 


c 


E0621 


989 


c 


E0920 


989 


c 


El 050 


989 


c 


E0625 


989 


c 


E0930 


989 


c 


El 060 


989 


c 


E0627 


989 


c 


E0935 


989 


c 


£1065 


989 


c 


E0628 


989 


c 


E0940 


989 


c 


E1066 


989 


c 


E0629 


989 


c 


E0941 


989 


c 


El 069 


989 


c 


E0630 


989 


c 


E0942 


989 


c 


El 070 


989 


c 


E0635 


989 


c 


E0943 


989 


c 


El 083 


989 


c 


E0650 


989 


c 


E0944 


989 


c 


El 084 


989 


c 


E0651 


989 


c 


E0945 


989 


c 


El 085 


989 


c 


E0652 


989 


c 


E0946 


989 


c 


El 086 


989 


c 


E0655 


989 


c 


E0947 


989 


c 


El 087 


989 


c 


E0660 


989 


c 


E0948 


989 


c 


El 088 


989 


c 


E0665 


989 


c 


E0950 


989 


c 


El 089 


989 


c 


E0666 


989 


c 


E0951 


989 


c 


El 090 


989 


c 


E0667 


989 


c 


E0952 


989 


c 


E1091 


989 


c 


E0668 


989 


c 


E0953 


989 


c 


El 092 


989 


c 


E0669 


989 


c 


E0954 


989 


c 


El 093 


989 


c 


E0670 


989 


c 


E0958 


989 


c 


EllOO 


989 


c 


E0671 


989 


c 


E0959 


989 


c 


ElllO 


989 


c 


E0672 


989 


c 


E0961 


989 


c 


El 130 


989 


c 


E0673 


989 


c 


E0962 


989 


c 


El 140 


989 


c 


E0690 


989 


c 


E0963 


989 


c 


E1150 


989 


c 


E0700 


989 


c 


E0964 


989 


c 


El 160 


989 


c 


E0710 


989 


c 


E0965 


989 


c 


El 170 


989 


c 


E0720 


989 


c 


E0966 


989 


c 


E1171 


989 


c 


E0730 


989 


c 


E0967 


989 


c 


E1172 


989 


c 


E0731 


989 


c 


E0968 


989 


c 


El 180 


989 


c 


E0740 


989 


c 


E0969 


989 


c 


El 190 


989 


c 


E0744 


989 


c 


E0970 


989 


c 


El 195 


989 


c 


E0745 


989 


c 


E0971 


989 


c 


El 200 


989 


c 


E0746 


989 


c 


E0972 


989 


c 


E1210 


989 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



181 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


E1211 


989 


C 


El 550 


989 


C 


G0039 


282 


C 


E1212 


989 


C 


El 560 


989 


C 


G0040 


282 


C 


E1213 


989 


c 


E1570 


989 


C 


G0041 


282 


C 


E1220 


989 


c 


El 575 


989 


C 


G0042 


282 


c 


E1221 


989 


c 


E1580 


989 


C 


G0043 


282 


c 


El 222 


989 


c 


El 590 


989 


C 


G0044 


282 


c 


El 223 


989 


c 


El 592 


989 


C 


G0045 


282 


C 


El 224 


989 


c 


El 594 


989 


c 


G0046 


282 


c 


E1225 


989 


c 


E1600 


989 


C 


G0047 


282 


C 


E1226 


989 


c 


E1610 


989 


C 


G0050 


275 


M 


E1227 


989 


c 


E1615 


989 


C 


G0054 


365 


C 


E1228 - 


989 


c 


El 620 


989 


C 


G0055 


365 


C 


E1230 


989 


c 


El 625 


989 


C 


G0056 


365 


C 


El 240 


989 


c 


El 630 


989 


C 


G0057 


365 


C 


E1250 


989 


c 


El 632 


989 


C 


G0058 


365 


C 


E1260 


989 


c 


El 635 


989 


C 


G0059 


365 


c 


E1270 


989 


c 


El 636 


989 


C 


G0060 


365 


c 


E1280 


989 


c 


E1640 


989 


C 


G0061 


993 


C 


E1285 


989 


c 


El 699 


989 


C 


H5300 


316 


c 


E1290 


989 


c 


El 700 


989 


C 


JOllO 


396 


C 


El 295 


989 


c 


E1701 


989 


C 


J0120 


396 


C 


El 296 


989 


c 


El 702 


989 


C 


J0150 


396 


C 


E1297 


989 


c 


El 800 


989 


C 


J0170 


396 


C 


E1298 


989 


c 


El 805 


989 


C 


J0190 


396 


c 


E1300 


989 


c 


E1810 


989 


C 


J0205 


396 


c 


E1310 


989 


c 


E1815 


989 


C 


J0210 


396 


C 


E1350 


989 


c 


El 820 


989 


C 


J0220 


396 


c 


E1353 


989 


c 


El 825 


989 


c 


J0230 


396 


C 


E1355 


989 


c 


El 830 


989 


C 


J0240 


396 


C 


E1372 


989 


c 


GOOOl 


090 


C 


J0256 


396 


c 


El 375 


989 


c 


G0002 


133 


C 


J0280 


396 


C 


El 377 


989 


c 


G0004 


071 


M 


J0290 


396 


C 


E1378 


989 


c 


G0005 


071 


T 


J0295 


396 


C 


El 379 


989 


c 


G0006 


071 


M 


J0300 


396 


C 


E1380 


989 


c 


G0007 


071 


P 


J0330 


396 


C 


E1381 


989 


c 


G0008 


330 


C 


J0340 


396 


C 


E1382 


989 


c 


G0009 


330 


C 


J0350 


396 


c 


E1383 


989 


c 


GOO 10 


330 


C 


J0360 


396 


c 


E1384 


989 


c 


G0015 


071 


T 


J0380 


396 


C 


E1385 


989 


c 


G0016 


071 


P 


J0390 


396 


c 


El 399 


989 


c 


G0025 


350 


M 


J0400 


396 


c 


E1400 


989 


c 


G0026 


371 


C 


J0460 


396 


C 


E1401 


989 


c 


G0027 


357 


C 


J0470 


396 


C 


El 402 


989 


c 


G0030 


282 


c 


J0475 


396 


C 


El 403 


989 


c 


G0031 


282 


c 


J0500 


396 


C 


El 404 


989 


c 


G0032 


282 


c 


JOS 10 


396 


c 


E1405 


989 


c 


G0033 


282 


c 


JOS 15 


396 


C 


El 406 


989 


c 


G0034 


282 


c 


J0S20 


396 


C 


E1510 


989 


c 


G0035 


282 


c 


J0530 


396 


c 


E1520 


989 


c 


G0036 


282 


c 


J0540 


396 


c 


E1530 


989 


c 


G0037 


282 


c 


J0S50 


396 


C 


El 540 


989 


c 


G0038 


282 


c 


J0S60 


396 


C 


182 














Final 


Report 



Ww.Wfi 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


J0570 


396 


C 


J 1080 


396 


C 


J 1630 


396 


C 


J0580 


396 


C 


J1090 


396 


C 


J1631 


396 


C 


J0585 


396 


c 


J 1095 


396 


C 


J 1640 


396 


C 


J0590 


396 


c 


JllOO 


396 


c 


J 1642 


396 


C 


J0600 


396 


c 


JlllO 


396 


c 


J 1644 


396 


C 


J0610 


396 


c 


J1120 


396 


c 


J 1650 


396 


C 


J0620 


396 


c 


J1155 


396 


c 


J 1660 


396 


C 


J0630 


396 


c 


J1160 


396 


c 


J 1670 


396 


C 


J0635 


396 


c 


J1165 


396 


c 


J 1690 


396 


C 


J0640 


395 


c 


J1170 


396 


c 


J 1700 


396 


C 


J0670 


. 396 


c 


J1180 


396 


c 


J1710 


396 


C 


J0680 - 


396 


c 


J 1200 


396 


c 


J1720 


396 


c 


J0690 


396 


c 


J 1205 


396 


c 


J1730 


396 


c 


J0694 


396 


c 


J1212 


396 


c 


J1739 


396 


c 


J0695 


396 


c 


J1230 


396 


c 


J1741 


396 


c 


J0696 


396 


c 


J 1240 


396 


c 


J 1760 


396 


c 


J0697 


396 


c 


J1245 


396 


c 


J 1770 


396 


c 


J0698 


396 


c 


J 1250 


396 


c 


J 1780 


396 


c 


J0700 


396 


c 


J 1320 


396 


c 


J1785 


396 


c 


J0702 


396 


c 


J1330 


396 


c 


J 1790 


396 


c 


J0704 


396 


c 


J 1340 


396 


c 


J 1800 


396 


c 


J0710 


396 


c 


J1350 


396 


c 


J1810 


396 


c 


J0713 


396 


c 


J 1360 


396 


c 


J 1820 


396 


c 


J0715 


396 


c 


J 1362 


396 


c 


J1830 


391 


c 


J0720 


396 


c 


J1364 


396 


c 


J 1840 


396 


c 


J0725 


396 


c 


J1380 


396 


c 


J 1850 


396 


c 


J0730 


396 


c 


J 1390 


396 


c 


J 1885 


396 


c 


J0743 


396 


c 


J1410 


396 


c 


J 1890 


396 


c 


J0745 


396 


c 


J 1435 


396 


c 


J1910 


396 


c 


J0760 


396 


c 


J1436 


396 


c 


J 1930 


396 


c 


J0770 


396 


c 


J 1440 


396 


c 


J 1940 


396 


c 


J0780 


396 


c 


J1441 


396 


c 


J1950 


395 


c 


J0790 


396 


c 


J 1455 


396 


c 


J1955 


396 


c 


J0800 


396 


c 


J 1460 


396 


c 


J 1960 


396 


c 


J0810 


396 


c 


J 1470 


396 


c 


J 1970 


396 


c 


J0820 


396 


c 


J 1480 


396 


c 


J 1980 


396 


c 


J0830 


396 


c 


J 1490 


396 


c 


J 1990 


396 


c 


J0835 


396 


c 


J1500 


396 


c 


J2000 


396 


c 


J0840 


396 


c 


J1510 


396 


c 


J2010 


396 


c 


J0850 


396 


c 


J1520 


396 


c 


J2050 


396 


c 


J0895 


396 


c 


J1530 


396 


c 


J2060 


396 


c 


J0900 


396 


c 


J 1540 


396 


c 


J2100 


396 


c 


J0945 


396 


c 


J1550 


396 


c 


J2150 


396 


c 


J0970 


396 


c 


J1560 


396 


c 


J2160 


396 


c 


J 1000 


396 


c 


J1561 


396 


c 


J2175 


396 


c 


J 1020 


396 


c 


J1562 


396 


c 


J2180 


396 


c 


J 1030 


396 


c 


J 1570 


396 


c 


J2190 


396 


c 


J 1040 


396 


c 


J1580 


396 


c 


J2210 


396 


c 


J 1050 


396 


c 


J 1600 


396 


c 


J2240 


396 


c 


J 1055 


396 


c 


J1610 


396 


c 


J2250 


396 


c 


J 1 060 


396 


c 


J 1620 


391 


c 


J2260 


391 


c 


J 1070 


396 


c 


J 1625 


396 


c 


J2270 


396 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



183 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


J2275 


396 


C 


J2912 


396 


C 


J3520 


396 


C 


J2300 


396 


C 


J2914 


396 


C 


J3530 


396 


C 


J2310 


396 


c 


J2920 


396 


C 


J3535 


396 


c 


J2320 


396 


c 


J2930 


396 


C 


J3540 


396 


C 


J2321 


396 


c 


J2950 


396 


C 


J3550 


396 


c 


J2322 


396 


c 


J2970 


396 


C 


J3560 


396 


c 


J2330 


396 


c 


J2995 


396 


C 


J3570 


995 


c 


J2350 


396 


c 


J2996 


396 


C 


J6015 


330 


c 


J2360 


396 


c 


J3000 


396 


C 


J7010 


330 


c 


J2370 


396 


c 


J3005 


396 


C 


J7020 


330 


C 


J2400 


. 396 


c 


J3010 


396 


C 


J7030 


403 


c 


J2405 - 


396 


c 


J3030 


396 


C 


J7040 


403 


C 


J2410 


396 


c 


J3050 


396 


C 


J7042 


403 


c 


J2430 


391 


c 


J3070 


396 


C 


J7050 


403 


C 


J2440 


396 


c 


J3080 


396 


C 


J7051 


403 


c 


J2460 


396 


c 


J3105 


396 


C 


J7060 


403 


C 


J2480 


396 


c 


J3120 


396 


C 


J7070 


403 


c 


J2490 


396 


c 


J3130 


396 


C 


J7080 


403 


C 


J2495 


396 


c 


J3140 


396 


C 


J7090 


403 


C 


J2510 


396 


c 


J3150 


396 


C 


J7100 


403 


c 


J2512 


396 


c 


J3180 


396 


C 


J7110 


403 


C 


J25I5 


396 


c 


J3230 


396 


C 


J7120 


403 


c 


J2520 


396 


c 


J3240 


396 


C 


J7130 


403 


c 


J2540 


396 


c 


J3250 


396 


c 


J7140 


989 


C 


J2545 


396 


c 


J3260 


396 


c 


J7I50 


989 


c 


J2550 


396 


c 


J3265 


396 


c 


J7190 


396 


c 


J2560 


396 


c 


J3270 


396 


C 


J7191 


396 


c 


J2590 


396 


c 


J3280 


396 


c 


J7192 


396 


C 


J2595 


396 


c 


J3301 


396 


C 


J7194 


396 


c 


J2597 


396 


c 


J3302 


396 


c 


J7196 


396 


C 


J2600 


396 


c 


J3303 


396 


c 


J7197 


396 


C 


J2640 


396 


c 


J3305 


396 


c 


J7300 


403 


C 


J2650 


396 


c 


J3310 


396 


c 


J7500 


396 


c 


J2670 


396 


c 


J3320 


396 


c 


J7501 


394 


C 


J2672 


396 


c 


J3340 


396 


c 


J7502 


396 


c 


J2675 


396 


c 


J3350 


396 


c 


J7503 


396 


C 


J2680 


396 


c 


J3360 


396 


c 


J7504 


393 


c 


J2690 


396 


c 


J3364 


396 


c 


J7505 


393 


c 


J2700 


396 


c 


J3365 


396 


c 


J7506 


396 


c 


J2710 


396 


c 


J3370 


396 


c 


J7507 


396 


c 


J2720 


396 


c 


J3380 


396 


c 


J7508 


396 


c 


J2725 


396 


c 


J3390 


396 


c 


J7509 


396 


C 


J2730 


396 


c 


J3400 


396 


c 


J7510 


396 


C 


J2760 


396 


c 


J3410 


396 


c 


J7599 


396 


C 


J2765 


396 


c 


J3420 


396 


c 


J7610 


396 


c 


J2790 


396 


c 


J3430 


396 


c 


J7615 


396 


c 


J2800 


396 


c 


J3450 


396 


c 


J7620 


396 


C 


J2810 


396 


c 


J3470 


396 


c 


J7625 


396 


C 


J2820 


396 


c 


J3475 


396 


c 


J7627 


396 


C 


J2825 


396 


c 


J3480 


396 


c 


J7630 


396 


C 


J2860 


396 


c 


J3490 


396 


c 


J7640 


396 


C 


J29I0 


396 


c 


J 3500 


396 


c 


J7645 


396 


c 


184 














Final 


Report 



•^V^'* 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


J7650 


396 


C 


J9202 


395 


C 


K0021 


989 


C 


J7651 


396 


C 


J9208 


394 


C 


K0022 


989 


C 


J7652 


396 


C 


J9209 


394 


C 


K0023 


989 


C 


J7653 


396 


C 


J9211 


392 


C 


K0024 


989 


C 


J7654 


396 


C 


J9213 


392 


C 


K0025 


989 


C 


J7655 


396 


C 


J9214 


391 


C 


K0026 


989 


C 


J7660 


396 


C 


J9215 


391 


c 


K0027 


989 


C 


J7665 


396 


C 


J9216 


394 


C 


K0028 


989 


C 


J7670 


396 


C 


J9217 


395 


C 


K0029 


989 


C 


J7672 


396 


c 


J9218 


391 


c 


K0030 


989 


C 


J7675 


. 396 


c 


J9230 


391 


C 


K0031 


989 


C 


J7699 - 


396 


c 


J9240 


391 


C 


K0032 


989 


C 


J7799 


396 


c 


J9245 


394 


C 


K0033 


989 


C 


J8499 


396 


c 


J9250 


391 


c 


K0034 


989 


C 


J8530 


391 


c 


J9260 


391 


C 


K0035 


989 


C 


J8560 


391 


c 


J9265 


392 


C 


K0036 


989 


C 


J8600 


391 


c 


J9266 


391 


C 


K0037 


989 


C 


J8610 


391 


c 


J9268 


392 


C 


K0038 


989 


C 


J8999 


391 


c 


J9270 


393 


C 


K0039 


989 


C 


J9000 


392 


c 


J9280 


393 


C 


K0040 


989 


c 


J9010 


394 


c 


J9290 


395 


C 


K0041 


989 


C 


J9015 


391 


c 


J9291 


395 


c 


K0042 


989 


C 


J9020 


392 


c 


J9293 


395 


C 


K0043 


989 


C 


J9031 


394 


c 


J9295 


392 


C 


K0044 


989 


C 


J9040 


394 


c 


J9320 


393 


C 


K0045 


989 


C 


J9045 


393 


c 


J9340 


393 


c 


K0046 


989 


C 


J9050 


393 


c 


J9360 


391 


c 


K0047 


989 


c 


J9060 


392 


c 


J9370 


392 


c 


K0048 


989 


C 


J9062 


394 


c 


J9375 


393 


c 


K0049 


989 


C 


J9065 


392 


c 


J9380 


393 


c 


K0050 


989 


c 


J9070 


391 


c 


J9390 


391 


C 


K0051 


989 


c 


J9080 


391 


c 


J9999 


391 


c 


K0052 


989 


c 


J9090 


391 


c 


KOOOl 


989 


C 


K0053 


989 


c 


J9091 


392 


c 


K0(X)2 


989 


C 


K0054 


989 


c 


J9092 


392 


c 


K0003 


989 


C 


K0055 


989 


c 


J9093 


391 


c 


K0004 


989 


C 


K0056 


989 


c 


J9094 


391 


c 


K0005 


989 


c 


K0057 


989 


c 


J9095 


391 


c 


K0006 


989 


c 


K0058 


989 


c 


J9096 


392 


c 


K0007 


989 


C 


K0059 


989 


c 


J9097 


392 


c 


KOOOS 


989 


c 


K0060 


989 


c 


J9100 


391 


c 


K0(X)9 


989 


C 


K0061 


989 


c 


J9110 


391 


c 


KOOlO 


989 


C 


K0062 


989 


c 


J9120 


391 


c 


KOOU 


989 


c 


K0063 


989 


c 


J9130 


391 


c 


K0012 


989 


c 


K0064 


989 


c 


J9140 


391 


c 


K0013 


989 


C 


K0065 


989 


c 


J9150 


392 


c 


K0014 


989 


c 


K0066 


989 


c 


J9165 


391 


c 


K0015 


989 


c 


K0067 


989 


c 


J9181 


391 


c 


K0016 


989 


C 


K0068 


989 


c 


J9182 


393 


c 


K0017 


989 


c 


K0069 


989 


c 


J9185 


393 


c 


K0018 


989 


c 


K0070 


989 


c 


J9190 


391 


c 


K0019 


989 


C 


K0071 


989 


c 


J9200 


393 


c 


K0020 


989 


c 


K0072 


989 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



183 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


K0073 


989 


C 


K0125 


396 


C 


KOI 84 


989 


C 


K0074 


989 


c 


KOI 26 


403 


C 


KOI 85 


989 


C 


K0075 


989 


c 


KOI 27 


403 


C 


KOI 86 


989 


C 


K0076 


989 


c 


KOI 28 


403 


C 


KOI 87 


989 


C 


K0077 


989 


c 


K0129 


403 


C 


KOI 88 


989 


C 


K0078 


989 


c 


KOI 30 


403 


C 


KOI 89 


989 


C 


K0079 


989 


c 


K0131 


403 


c 


KOI 90 


989 


C 


K0080 


989 


c 


K0132 


403 


c 


K0191 


989 


C 


K0081 


989 


c 


K0133 


403 


c 


KOI 92 


989 


C 


K0082 


989 


c 


KOI 34 


403 


c 


K0193 


989 


C 


K0083 


. 989 


c 


KOI 35 


403 


c 


K0194 


989 


C 


K0084 . 


989 


c 


KOI 36 


403 


c 


KOI 95 


989 


C 


K0085 


989 


c 


KOI 37 


403 


c 


KOI 96 


403 


C 


K0086 


989 


c 


KOI 38 


403 


c 


K0197 


403 


C 


K0087 


989 


c 


K0139 


403 


c 


KOI 98 


403 


C 


K0088 


989 


c 


K0140 


396 


c 


KOI 99 


403 


C 


K0089 


989 


c 


K0141 


396 


c 


K0203 


403 


C 


K0090 


989 


c 


K0142 


396 


c 


K0204 


403 


C 


K0091 


989 


c 


K0143 


396 


c 


K0205 


403 


C 


K0092 


989 


c 


KOI 44 


396 


c 


K0206 


403 


C 


K0093 


989 


c 


K0145 


396 


c 


K0207 


403 


C 


K0094 


989 


c 


K0146 


396 


c 


K0208 


403 


C 


K0095 


989 


c 


K0147 


403 


c 


K0209 


403 


C 


K0096 


989 


c 


K0148 


403 


c 


K0210 


403 


C 


K0097 


989 


c 


K0149 


403 


c 


K0211 


403 


C 


K0098 


989 


c 


K0I50 


403 


c 


K0212 


403 


C 


K0099 


989 


c 


K0151 


403 


c 


K0213 


403 


c 


KOI 00 


989 


c 


K0152 


403 


c 


K0214 


403 


c 


KOlOl 


989 


c 


K0153 


403 


c 


K0215 


403 


c 


KG 102 


989 


c 


K0154 


403 


c 


K0216 


403 


c 


KOI 03 


989 


c 


KOI 62 


989 


c 


K0217 


403 


c 


KOI 04 


989 


c 


K0163 


989 


c 


K0218 


403 


c 


KOI 05 


989 


c 


K0164 


989 


c 


K0219 


403 


c 


KOI 06 


989 


c 


KOI 65 


989 


c 


K0220 


403 


c 


KOI 07 


989 


c 


K0166 


989 


c 


K0221 


403 


c 


KOI 08 


989 


c 


K0167 


989 


c 


K0222 


403 


c 


K0109 


989 


c 


KOI 68 


989 


c 


K0223 


403 


c 


KOllO 


989 


c 


K0I69 


989 


c 


K0224 


403 


c 


KOI 11 


989 


c 


KOI 70 


989 


c 


K0228 


403 


c 


KOI 12 


989 


c 


K0171 


989 


c 


K0229 


403 


c 


KOI 13 


989 


c 


KOI 72 


989 


c 


K0230 


403 


c 


KOI 14 


989 


c 


K0173 


989 


c 


K0234 


403 


c 


KOI 15 


989 


c 


K0174 


989 


c 


K0235 


403 


c 


KOI 16 


989 


c 


K0175 


989 


c 


K0236 


403 


c 


KOI 17 


989 


c 


KOI 76 


989 


c 


K0237 


403 


c 


K0118 


989 


c 


KOI 77 


989 


c 


K0238 


403 


c 


KOI 19 


396 


c 


K0178 


989 


c 


K0239 


403 


c 


K0120 


396 


c 


KOI 79 


989 


c 


K0240 


403 


c 


K0121 


396 


c 


KOI 80 


989 


c 


K0241 


403 


c 


KOI 22 


396 


c 


K0181 


989 


c 


K0242 


403 


c 


KOI 23 


396 


c 


KOI 82 


989 


c 


K0243 


403 


c 


KOI 24 


396 


c 


KOI 83 


989 


c 


K0244 


403 


c 


186 














Final 


Report 



.w**** 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


K0245 


403 


C 


LOlOO 


989 


C 


L0920 


989 


C 


K0246 


403 


c 


LOllO 


989 


C 


L0930 


989 


C 


K0247 


403 


c 


L0120 


989 


C 


L0940 


989 


C 


K0248 


403 


c 


L0130 


989 


C 


L0950 


989 


C 


K0249 


403 


c 


L0140 


989 


c 


L0960 


989 


C 


K0250 


403 


c 


L0150 


989 


C 


L0970 


989 


C 


K0251 


403 


c 


L0160 


989 


c 


L0972 


989 


C 


K0252 


403 


c 


L0170 


989 


c 


L0974 


989 


C 


K0253 


403 


c 


L0172 


989 


C 


L0976 


989 


C 


K0254 


403 


c 


L0174 


989 


C 


L0978 


989 


C 


K0255 


. 403 


c 


L0180 


989 


C 


L0980 


989 


C 


K0256 . 


403 


c 


L0190 


989 


c 


L0982 


989 


C 


K0257 


403 


c 


L0200 


989 


C 


L0984 


989 


C 


K0258 


403 


c 


L0210 


989 


c 


LIOOO 


989 


C 


K0259 


403 


c 


L0220 


989 


C 


LlOlO 


989 


C 


K0260 


403 


c 


L0300 


989 


C 


LI 020 


989 


C 


K0261 


403 


c 


L0310 


989 


c 


LI 025 


989 


C 


K0262 


403 


c 


L0315 


989 


C 


LI 030 


989 


C 


K0263 


403 


c 


L0317 


989 


c 


L1040 


989 


C 


K0264 


403 


c 


L0320 


989 


C 


LI 050 


989 


c 


K0265 


403 


c 


L0330 


989 


c 


L1060 


989 


C 


K0266 


403 


c 


L0340 


989 


c 


LI 070 


989 


C 


K0268 


989 


c 


L0350 


989 


C 


LI 080 


989 


C 


K0269 


989 


c 


L0360 


989 


c 


L1085 


989 


C 


K0270 


989 


c 


L0370 


989 


C 


LI 090 


989 


C 


K0271 


989 


c 


L0380 


989 


C 


LllOO 


989 


C 


K0272 


989 


c 


L0390 


989 


C 


LlllO 


989 


C 


K0273 


989 


c 


L0400 


989 


C 


LI 120 


989 


C 


K0274 


989 


c 


L0410 


989 


C 


LI 200 


989 


c 


K0275 


989 


c 


L0420 


989 


c 


L1210 


989 


C 


K0276 


989 


c 


L0430 


989 


C 


L1220 


989 


c 


K0277 


989 


c 


L0440 


989 


c 


L1230 


989 


C 


K0278 


989 


c 


L0500 


989 


C 


LI 240 


989 


C 


K0279 


989 


c 


LOS 10 


989 


C 


L1250 


989 


c 


K0280 


989 


c 


L0515 


989 


C 


LI 260 


989 


c 


K0281 


403 


c 


L0520 


989 


C 


L1270 


989 


C 


K0283 


403 


c 


L0530 


989 


C 


LI 280 


989 


c 


K0284 


989 


c 


L0540 


989 


C 


LI 290 


989 


C 


K0285 


989 


c 


L0550 


989 


C 


LI 300 


989 


C 


K0400 


989 


c 


L0560 


989 


C 


L1310 


989 


c 


K0401 


989 


c 


L0565 


989 


c 


LI 499 


989 


C 


K0402 


403 


c 


L0600 


989 


C 


L1500 


989 


C 


K0403 


403 


c 


L0610 


989 


C 


L15I0 


989 


c 


K0404 


403 


c 


L0620 


989 


C 


LI 520 


989 


C 


K0405 


403 


c 


L0700 


989 


C 


LI 600 


989 


C 


K0406 


403 


c 


L0710 


989 


c 


L1610 


989 


C 


K0407 


989 


c 


L0810 


989 


C 


LI 620 


989 


c 


K0408 


989 


c 


L0820 


989 


C 


L1630 


989 


C 


K0409 


403 


c 


L0830 


989 


C 


L1640 


989 


C 


K0410 


403 


c 


L0860 


989 


C 


LI 650 


989 


C 


K04I1 


403 


c 


L0900 


989 


C 


LI 660 


989 


C 


K0412 


396 


c 


L0910 


989 


c 


LI 680 


989 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



187 



APPENDIX E 


















Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


L1685 


989 


C 


L2080 


989 


C 


L2435 


989 


C 


LI 686 


989 


C 


L2090 


989 


C 


L2492 


989 


C 


L1700 


989 


c 


L2102 


989 


C 


L2500 


989 


C 


L1710 


989 


c 


L2104 


989 


C 


L2510 


989 


c 


L1720 


989 


c 


L2106 


989 


C 


L2520 


989 


C 


LI 730 


989 


c 


L2108 


989 


C 


L2525 


989 


c 


L1750 


989 


c 


L2112 


989 


C 


L2526 


989 


c 


L1755 


989 


c 


L2114 


989 


C 


L2530 


989 


C 


L1800 


989 


c 


L2116 


989 


C 


L2540 


989 


c 


L1810 


989 


c 


L2122 


989 


C 


L2550 


989 


C 


L1815 . 


989 


c 


L2124 


989 


C 


L2570 


989 


C 


L1820. 


989 


c 


L2126 


989 


C 


L2580 


989 


C 


L1825 


989 


c 


L2128 


989 


c 


L2600 


989 


c 


LI 830 


989 


c 


L2132 


989 


C 


L2610 


989 


C 


L1832 


989 


c 


L2134 


989 


C 


L2620 


989 


c 


LI 834 


989 


c 


L2136 


989 


C 


L2622 


989 


c 


LI 840 


989 


c 


L2180 


989 


C 


L2624 


989 


C 


LI 844 


989 


c 


L2182 


989 


C 


L2627 


989 


c 


LI 845 


989 


c 


L2184 


989 


C 


L2628 


989 


C 


LI 846 


989 


c 


L2186 


989 


c 


L2630 


989 


C 


LI 850 


989 


c 


L2188 


989 


C 


L2640 


989 


c 


L1855 


989 


c 


L2190 


989 


C 


L2650 


989 


c 


L1858 


989 


c 


L2192 


989 


C 


L2660 


989 


C 


LI 860 


989 


c 


L2200 


989 


C 


L2670 


989 


c 


L1870 


989 


c 


L2210 


989 


c 


L2680 


989 


C 


L1880 


989 


c 


L2220 


989 


C 


L2750 


989 


C 


L1885 


989 


c 


L2230 


989 


C 


L2760 


989 


C 


LI 900 


989 


c 


L2240 


989 


C 


L2770 


989 


C 


L1902 


989 


c 


L2250 


989 


C 


L2780 


989 


C 


LI 904 


989 


c 


L2260 


989 


C 


L2785 


989 


C 


LI 906 


989 


c 


L2265 


989 


c 


L2795 


989 


c 


L1910 


989 


c 


L2270 


989 


C 


L2800 


989 


C 


LI 920 


989 


c 


L2275 


989 


C 


L28I0 


989 


C 


L1930 


989 


c 


L2280 


989 


C 


L2820 


989 


C 


LI 940 


989 


c 


L2300 


989 


C 


L2830 


989 


C 


LI 945 


989 


c 


L2310 


989 


C 


L2840 


989 


C 


L1950 


989 


c 


L2320 


989 


C 


L2850 


989 


C 


LI 960 


989 


c 


L2330 


989 


C 


L2860 


989 


c 


LI 970 


989 


c 


L2335 


989 


c 


L2999 


989 


c 


L1980 


989 


c 


L2340 


989 


C 


L3000 


989 


C 


LI 990 


989 


c 


L2350 


989 


C 


L3001 


989 


C 


L2000 


989 


c 


L2360 


989 


c 


L3002 


989 


C 


L2010 


989 


c 


L2370 


989 


C 


L3003 


989 


c 


L2020 


989 


c 


L2375 


989 


C 


L3010 


989 


C 


L2030 


989 


c 


L2380 


989 


C 


L3020 


989 


C 


L2036 


989 


c 


L2385 


989 


C 


L3030 


989 


c 


L2037 


989 


c 


L2390 


989 


C 


L3040 


989 


C 


L2038 


989 


c 


L2395 


989 


C 


L3050 


989 


C 


L2040 


989 


c 


L2397 


989 


C 


L3060 


989 


C 


L2050 


989 


c 


L2405 


989 


c 


L3070 


989 


C 


L2060 


989 


c 


L2415 


989 


C 


L3080 


989 


C 


L2070 


989 


c 


L2425 


989 


C 


L3090 


989 


C 


188 














Final 


Report 



m- 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


L3100 


989 


C 


L3430 


989 


C 


L3906 


989 


C 


L3140 


989 


C 


L3440 


989 


C 


L3907 


989 


C 


L3150 


989 


C 


L3450 


989 


C 


L3908 


989 


C 


L3160 


989 


C 


L3455 


989 


C 


L3910 


989 


C 


L3170 


989 


C 


L3460 


989 


C 


L3912 


989 


C 


L3201 


989 


C 


L3465 


989 


C 


L3914 


989 


C 


L3202 


989 


C 


L3470 


989 


C 


L3916 


989 


C 


L3203 


989 


C 


L3480 


989 


C 


L3918 


989 


C 


L3204 


989 


C 


L3485 


989 


C 


L3920 


989 


C 


L3206 


989 


C 


L3500 


989 


c 


L3922 


989 


C 


L3207 . 


989 


C 


L3510 


989 


c 


L3924 


989 


C 


L3208 . 


989 


C 


L3520 


989 


C 


L3926 


989 


C 


L3209 


989 


C 


L3530 


989 


c 


L3928 


989 


c 


L3211 


989 


C 


L3540 


989 


C 


L3930 


989 


c 


L3212 


989 


C 


L3550 


989 


c 


L3932 


989 


c 


L3213 


989 


c 


L3560 


989 


c 


L3934 


989 


c 


L3214 


989 


c 


L3570 


989 


C 


L3936 


989 


c 


L3215 


989 


c 


L3580 


989 


c 


L3938 


989 


c 


L3216 


989 


c 


L3590 


989 


C 


L3940 


989 


c 


L3217 


989 


c 


L3595 


989 


c 


L3942 


989 


c 


L3218 


989 


c 


L3600 


989 


C 


L3944 


989 


c 


L3219 


989 


c 


L3610 


989 


C 


L3946 


989 


c 


L3221 


989 


c 


L3620 


989 


C 


L3948 


989 


c 


L3222 


989 


c 


L3630 


989 


C 


L3950 


989 


c 


L3223 


989 


c 


L3640 


989 


C 


L3952 


989 


c 


L3224 


989 


c 


L3649 


989 


c 


L3954 


989 


c 


L3225 


989 


c 


L3650 


989 


C 


L3960 


989 


c 


L3230 


989 


c 


L3660 


989 


C 


L3962 


989 


c 


L3250 


989 


c 


L3670 


989 


C 


L3%3 


989 


c 


L3251 


989 


c 


L3700 


989 


C 


L3964 


989 


c 


L3252 


989 


c 


L3710 


989 


C 


L3965 


989 


c 


L3253 


989 


c 


L3720 


989 


C 


L3966 


989 


c 


L3254 


989 


c 


L3730 


989 


C 


L3968 


989 


c 


L3255 


989 


c 


L3740 


989 


C 


L3969 


989 


c 


L3257 


989 


c 


L3800 


989 


c 


L3970 


989 


c 


L3260 


989 


c 


L3805 


989 


C 


L3972 


989 


c 


L3265 


989 


c 


L3810 


989 


c 


L3974 


989 


c 


L3300 


989 


c 


L3815 


989 


c 


L3980 


989 


c 


L3310 


989 


c 


L3820 


989 


c 


L3982 


989 


c 


L3320 


989 


c 


L3825 


989 


c 


L3984 


989 


c 


L3330 


989 


c 


L3830 


989 


c 


L3985 


989 


c 


L3332 


989 


c 


L3835 


989 


c 


L3986 


989 


c 


L3334 


989 


c 


L3840 


989 


c 


L3995 


989 


c 


L3340 


989 


c 


L3845 


989 


c 


L3999 


989 


c 


L3350 


989 


c 


L3850 


989 


c 


L4000 


989 


c 


L3360 


989 


c 


L3855 


989 


c 


L4010 


989 


c 


L3370 


989 


c 


L3860 


989 


c 


L4020 


989 


c 


L3380 


989 


c 


L3890 


989 


c 


L4030 


989 


c 


L3390 


989 


c 


L3900 


989 


c 


L4040 


989 


c 


L3400 


989 


c 


L3901 


989 


c 


L4045 


989 


c 


L3410 


989 


c 


L3902 


989 


c 


L4050 


989 


c 


L3420 


989 


c 


L3904 


989 


c 


L4055 


989 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



189 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


U060 


989 


C 


L5585 


989 


C 


L5670 


989 


C 


L4070 


989 


C 


L5590 


989 


C 


L5672 


989 


C 


L4080 


989 


C 


L5595 


989 


C 


L5674 


989 


c 


W090 


989 


C 


L5600 


989 


C 


L5675 


989 


c 


UlOO 


989 


C 


L5610 


989 


C 


L5676 


989 


C 


L4I10 


989 


C 


L5611 


989 


C 


L5677 


989 


c 


L4130 


989 


C 


L5613 


989 


C 


L5678 


989 


c 


L4200 


989 


C 


L5614 


989 


C 


L5680 


989 


C 


L4210 


989 


C 


L5616 


989 


C 


L5682 


989 


c 


L4310 


989 


C 


L5617 


989 


c 


L5684 


989 


c 


L4320 


. 989 


C 


L5618 


989 


C 


L5686 


989 


C 


L4350 . 


■ 989 


C 


L5620 


989 


C 


L5688 


989 


C 


L4360 


989 


C 


L5622 


989 


c 


L5690 


989 


c 


L4370 


989 


C 


L5624 


989 


C 


L5692 


989 


C 


L4380 


989 


C 


L5626 


989 


C 


L5694 


989 


c 


L5000 


989 


C 


L5628 


989 


C 


L5695 


989 


c 


L5010 


989 


C 


L5629 


989 


C 


L5696 


989 


C 


L5020 


989 


C 


L5630 


989 


C 


L5697 


989 


C 


L5050 


989 


C 


L5631 


989 


C 


L5698 


989 


c 


L5060 


989 


C 


L5632 


989 


C 


L5699 


989 


C 


L5100 


989 


C 


L5634 


989 


c 


L5700 


989 


c 


L5105 


989 


C 


L5636 


989 


c 


L5701 


989 


c 


L5150 


989 


C 


L5637 


989 


c 


L5702 


989 


c 


L5160 


989 


c 


L5638 


989 


c 


L5704 


989 


c 


L5200 


989 


c 


L5639 


989 


c 


L5705 


989 


c 


L5210 


989 


c 


L5640 


989 


c 


L5706 


989 


c 


L5220 


989 


c 


L5642 


989 


c 


L5707 


989 


C 


L5230 


989 


c 


L5643 


989 


c 


L5710 


989 


c 


L5250 


989 


c 


L5644 


989 


c 


L5711 


989 


c 


L5270 


989 


c 


L5645 


989 


c 


L5712 


989 


C 


L5280 


989 


c 


L5646 


989 


c 


L5714 


989 


c 


L5300 


989 


c 


L5647 


989 


c 


L5716 


989 


C 


L5310 


989 


c 


L5648 


989 


c 


L5718 


989 


C 


L5320 


989 


c 


L5649 


989 


c 


L5722 


989 


c 


L5330 


989 


c 


L5650 


989 


c 


L5724 


989 


C 


L5340 


989 


c 


L5651 


989 


c 


L5726 


989 


C 


L5400 


989 


c 


L5652 


989 


c 


L5728 


989 


c 


L5410 


989 


c 


L5653 


989 


c 


L5780 


989 


c 


L5420 


989 


c 


L5654 


989 


c 


L5785 


989 


C 


L5430 


989 


c 


L5655 


989 


c 


L5790 


989 


c 


L5450 


989 


c 


L5656 


989 


c 


L5795 


989 


C 


L5460 


989 


c 


L5658 


989 


c 


L5810 


989 


C 


L5500 


989 


c 


L5660 


989 


c 


L581I 


989 


c 


L5505 


989 


c 


L5661 


989 


c 


L5812 


989 


C 


L5510 


989 


c 


L5662 


989 


c 


L5816 


989 


C 


L5520 


989 


c 


L5663 


989 


c 


L5818 


989 


c 


L5530 


989 


c 


L5664 


989 


c 


L5822 


989 


C 


L5535 


989 


c 


L5665 


989 


c 


L5824 


989 


C 


L5540 


989 


c 


L5666 


989 


c 


L5828 


989 


C 


L5560 


989 


c 


L5667 


989 


c 


L5830 


989 


C 


L5570 


989 


c 


L5668 


989 


c 


L5840 


989 


C 


L5580 


989 


c 


L5669 


989 


c 


L5845 


989 


c 


190 














Final 


Report 



■•i^*'; 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


L5846 


989 


C 


L6550 


989 


C 


L6740 


989 


C 


L5850 


989 


C 


L6570 


989 


C 


L6745 


989 


C 


L5855 


989 


c 


L6580 


989 


c 


L6750 


989 


C 


L5910 


989 


c 


L6582 


989 


C 


L6755 


989 


C 


L5920 


989 


c 


L6584 


989 


C 


L6765 


989 


C 


L5925 


989 


c 


L6586 


989 


C 


L6770 


989 


C 


L5930 


989 


c 


L6588 


989 


C 


L6775 


989 


C 


L5940 


989 


c 


L6590 


989 


C 


L6780 


989 


C 


L5950 


989 


c 


L6600 


989 


C 


L6790 


989 


C 


L5960 


989 


c 


L6605 


989 


c 


L6795 


989 


C 


L5962 


. 989 


c 


L6610 


989 


C 


L6800 


989 


C 


L5964 - 


989 


c 


L6615 


989 


c 


L6805 


989 


C 


L5966 


989 


c 


L6616 


989 


C 


L6806 


989 


C 


L5970 


989 


c 


L6620 


989 


C 


L6807 


989 


C 


L5972 


989 


c 


L6623 


989 


C 


L6808 


989 


c 


L5974 


989 


c 


L6625 


989 


C 


L6809 


989 


C 


L5976 


989 


c 


L6628 


989 


C 


L6810 


989 


c 


L5978 


989 


c 


L6629 


989 


c 


L6825 


989 


C 


L5979 


989 


c 


L6630 


989 


C 


L6830 


989 


c 


L5980 


989 


c 


L6632 


989 


C 


L6835 


989 


C 


L5981 


989 


c 


L6635 


989 


C 


L6840 


989 


C 


L5982 


989 


c 


L6637 


989 


C 


L6845 


989 


c 


L5984 


989 


c 


L6640 


989 


C 


L6850 


989 


c 


L5985 


989 


c 


L6641 


989 


C 


L6855 


989 


C 


L5986 


989 


c 


L6642 


989 


C 


L6860 


989 


C 


L5999 


989 


c 


L6645 


989 


C 


L6865 


989 


C 


L6000 


989 


c 


L6650 


989 


c 


L6867 


989 


C 


L6010 


989 


c 


L6655 


989 


c 


L6868 


989 


C 


L6020 


989 


c 


L6660 


989 


C 


L6870 


989 


C 


L6O50 


989 


c 


L6665 


989 


C 


L6872 


989 


C 


L6055 


989 


c 


L6670 


989 


C 


L6873 


989 


C 


L6100 


989 


c 


L6672 


989 


C 


L6875 


989 


c 


L6110 


989 


c 


L6675 


989 


C 


L6880 


989 


C 


L6120 


989 


c 


L6676 


989 


C 


L6890 


989 


C 


L6130 


989 


c 


L6680 


989 


c 


L6895 


989 


C 


L6200 


989 


c 


L6682 


989 


c 


L6900 


989 


C 


L6205 


989 


c 


L6684 


989 


C 


L6905 


989 


c 


L6250 


989 


c 


L6686 


989 


C 


L6910 


989 


C 


L6300 


989 


c 


L6687 


989 


C 


L6915 


989 


c 


L6310 


989 


c 


L6688 


989 


C 


L6920 


989 


c 


L6320 


989 


c 


L6689 


989 


C 


L6925 


989 


c 


L6350 


989 


c 


L6690 


989 


C 


L6930 


989 


c 


L6360 


989 


c 


L6691 


989 


c 


L6935 


989 


c 


L6370 


989 


c 


L6692 


989 


c 


L6940 


989 


c 


L6380 


989 


c 


L6700 


989 


c 


L6945 


989 


c 


L6382 


989 


c 


L6705 


989 


c 


L6950 


989 


c 


L6384 


989 


c 


L6710 


989 


c 


L6955 


989 


c 


L6386 


989 


c 


L6715 


989 


c 


L6960 


989 


c 


L6388 


989 


c 


L6720 


989 


c 


L6965 


989 


c 


L6400 


989 


c 


L6725 


989 


c 


L6970 


989 


c 


L6450 


989 


c 


L6730 


989 


c 


L6975 


989 


c 


L6500 


989 


c 


L6735 


989 


c 


L7010 


989 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



191 



APPENDIX E 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


L7015 


989 


C 


L8420 


989 


C 


M 


319 


C 


L7020 


989 


C 


L8430 


989 


C 


M 


319 


C 


L7025 


989 


C 


L8435 


989 


C 


M 


422 


C 


L7030 


989 


C 


L8440 


989 


C 


M 


422 


C 


L7035 


989 


C 


L8460 


989 


C 


M 


422 


C 


L7040 


989 


C 


L8465 


989 


c 


M 


422 


C 


L7045 


989 


C 


L8470 


989 


C 


M 


423 


C 


L7160 


989 


C 


L8480 


989 


C 


M 


995 


C 


L7165 


989 


C 


L8485 


989 


C 


M 


995 


C 


L7170 


989 


C 


L8490 


989 


C 


M 


995 


C 


L7180 


. 989 


C 


L8499 


989 


C 


M 


995 


C 


L7185 - 


989 


C 


L8500 


989 


c 


M 


995 


C 


L7186 


989 


C 


L8501 


989 


C 


M 


995 


C 


L7I90 


989 


C 


L8600 


989 


C 


M 


995 


C 


L7191 


989 


C 


L8603 


989 


C 


P 


353 


C 


L7260 


989 


C 


L8605 


989 


C 


P 


353 


C 


L7261 


989 


C 


L8610 


989 


C 


P 


363 


C 


L7266 


989 


C 


L8611 


989 


C 


P 


367 


C 


L7272 


989 


C 


L8612 


989 


C 


P 


367 


C 


L7274 


989 


C 


L8613 


989 


c 


P 


367 


C 


L7360 


989 


C 


L8614 


989 


C 


P 


396 


c 


L7362 


989 


C 


L8615 


989 


C 


P 


396 


c 


L7364 


989 


C 


L8616 


989 


C 


P 


400 


c 


L7366 


989 


c 


L8617 


989 


c 


P 


400 


c 


L7499 


989 


c 


L8618 


989 


c 


P 


400 


c 


L7500 


989 


c 


L8619 


989 


c 


P 


400 


c 


L7510 


989 


c 


L8620 


989 


c 


P 


400 


c 


L8000 


989 


c 


L8621 


989 


c 


P 


400 


c 


L8010 


989 


c 


L8622 


989 


c 


P 


400 


c 


L8020 


989 


c 


L8623 


989 


c 


P 


400 


c 


L803O 


989 


c 


L8624 


989 


c 


P 


400 


c 


L8100 


989 


c 


L8625 


989 


c 


P 


400 


c 


L8110 


989 


c 


L8626 


989 


c 


P 


400 


c 


L8120 


989 


c 


L8627 


989 


c 


P 


989 


c 


L8130 


989 


c 


L8628 


989 


c 


P 


989 


c 


L8140 


989 


c 


L8629 


989 


c 


P 


989 


c 


L8150 


989 


c 


L8630 


989 


c 


P 


995 


c 


L8160 


989 


c 


L8640 


989 


c 


P 


995 


c 


L8170 


989 


c 


L8641 


989 


c 


P 


995 


c 


L8180 


989 


c 


L8642 


989 


c 


Q0034 


330 


c 


L8190 


989 


c 


L8655 


989 


c 


Q0035 


070 


M 


L8200 


989 


c 


L8656 


989 


c 


Q0047 


337 


c 


L8210 


989 


c 


L8657 


989 


c 


Q0068 


100 


c 


L8220 


989 


c 


L8658 


989 


c 


Q0081 


094 


c 


L8230 


989 


c 


L8670 


989 


c 


Q0082 


308 


c 


L8300 


989 


c 


L8680 


989 


c 


Q0083 


096 


c 


L8310 


989 


c 


L8690 


989 


c 


Q0084 


095 


c 


L8320 


989 


c 


L9999 


989 


c 


Q0085 


095 


c 


L8330 


989 


c 


M 


006 


c 


Q0086 


317 


c 


L8400 


989 


c 


M 


319 


c 


Q0091 


172 


c 


L8410 


989 


c 


M 


319 


c 


Q0092 


989 


c 


L8415 


989 


c 


M 


319 


c 


Q0093 


396 


c 


192 














Final 


Report 



'm 



:,SV 



Map of HCPCS Codes to PCGs 


Code 


PCG 


Class 


Code 


PCG 


Class 


Code 


PCG 


Class 


Q0094 


396 


C 


Q9938 


396 


C 


V2302 


989 


C 


Q0103 


317 


C 


Q9939 


396 


C 


V2303 


989 


C 


Q0104 


317 


C 


Q9940 


396 


c 


V2304 


989 


C 


Q0105 


995 


C 


R0070 


989 


c 


V2305 


989 


C 


Q0106 


995 


C 


R0075 


989 


c 


V2306 


989 


C 


Q0107 


995 


C 


R0076 


989 


c 


V2307 


989 


C 


Q0108 


995 


C 


V2020 


989 


c 


V2308 


989 


c 


Q0109 


316 


C 


V2025 


989 


c 


V2309 


989 


C 


QOllO 


316 


C 


V2100 


989 


c 


V2310 


989 


c 


QOlll 


358 


C 


V2101 


989 


c 


V23n 


989 


C 


Q0112 


358 


C 


V2102 


989 


C 


V2312 


989 


C 


Q0113 - 


358 


C 


V2103 


989 


c 


V2313 


989 


C 


Q0114 


350 


M 


V2104 


989 


c 


V2314 


989 


C 


Q0115 


350 


M 


V2105 


989 


c 


V2315 


989 


C 


Q0116 


371 


C 


V2106 


989 


c 


V2316 


989 


C 


Q0117 


989 


C 


V2107 


989 


c 


V2317 


989 


C 


Q01I8 


989 


C 


V2108 


989 


c 


V2318 


989 


C 


Q0119 


989 


C 


V2109 


989 


c 


V2319 


989 


C 


Q0120 


989 


C 


V2110 


989 


c 


V2320 


989 


C 


Q0121 


989 


C 


V2111 


989 


c 


V2399 


989 


c 


Q0122 


989 


C 


V2112 


989 


C 


V2410 


989 


C 


Q0123 


989 


C 


V2113 


989 


c 


V2430 


989 


C 


Q0124 


989 


C 


V2114 


989 


c 


V2499 


989 


C 


Q0125 


995 


C 


V2115 


989 


C 


V2500 


989 


C 


Q0126 


995 


c 


V2116 


989 


c 


V2501 


989 


C 


Q0127 


995 


c 


V2117 


989 


c 


V2502 


989 


C 


Q0128 


995 


c 


V2118 


989 


c 


V2503 


989 


C 


Q0129 


995 


c 


V2199 


989 


C 


V2510 


989 


c 


Q0130 


995 


c 


V2200 


989 


C 


V2511 


989 


C 


Q0132 


396 


c 


V2201 


989 


c 


V2512 


989 


C 


Q0134 


995 


c 


V2202 


989 


c 


V2513 


989 


C 


Q0135 


995 


c 


V2203 


989 


c 


V2520 


989 


C 


Q0136 


396 


c 


V2204 


989 


C 


V2521 


989 


c 


Q0138 


995 


c 


V2205 


989 


c 


V2522 


989 


c 


Q9920 


396 


c 


V2206 


989 


c 


V2523 


989 


c 


Q9921 


396 


c 


V2207 


989 


c 


V2530 


989 


C 


Q9922 


396 


c 


V2208 


989 


c 


V2531 


989 


c 


Q9923 


396 


c 


V2209 


989 


c 


V2599 


989 


C 


Q9924 


396 


c 


V2210 


989 


c 


V2600 


989 


C 


Q9925 


396 


c 


V2211 


989 


c 


V2610 


989 


c 


Q9926 


396 


c 


V2212 


989 


C 


V2615 


989 


c 


Q9927 


396 


c 


V2213 


989 


c 


V2623 


989 


C 


Q9928 


396 


c 


V2214 


989 


c 


V2624 


989 


C 


Q9929 


396 


c 


V2215 


989 


c 


V2625 


989 


c 


Q9930 


396 


c 


V2216 


989 


c 


V2626 


989 


C 


Q9931 


396 


c 


V2217 


989 


c 


V2627 


989 


c 


Q9932 


396 


c 


V2218 


989 


c 


V2628 


989 


c 


Q9933 


396 


c 


V2219 


989 


c 


V2629 


989 


C 


Q9934 


396 


c 


V2220 


989 


c 


V2630 


989 


c 


Q9935 


396 


c 


V2299 


989 


c 


V2631 


989 


c 


Q9936 


396 


c 


V2300 


989 


c 


V2632 


989 


C 


Q9937 


396 


c 


V2301 


989 


c 


V2700 


989 


c 



The Development of a Physician Prospective Payment System for Ambulatory Care 



193 



APPENDIX E 



Code 


PCG 


Class 


V27I0 


989 


C 


V2715 


989 


C 


V2718 


989 


C 


V2730 


989 


C 


V2740 


989 


C 


V2741 


989 


C 


V2742 


989 


C 


V2743 


989 


C 


V2744 


989 


C 


V2750 


989 


C 


V2755 


989 


C 


V2760 - 


989 


C 


V2770 


989 


C 


V2780 


989 


C 


V2781 


989 


C 


V2785 


989 


C 


V2799 


989 


C 


V5008 


318 


c 


V5010 


318 


c 


V5011 


989 


c 


V5014 


989 


c 


V5020 


989 


c 


V5030 


989 


c 


V5040 


989 


c 


V5050 


989 


c 


V5060 


989 


c 


V5070 


989 


c 


V5080 


989 


c 


V5090 


989 


c 


V5100 


989 


c 


V5110 


989 


c 


V5120 


989 


c 


V5130 


989 


c 


V5140 


989 


c 


V5150 


989 


c 


V5160 


989 


c 


V5170 


989 


c 


V5180 


989 


c 


V5190 


989 


c 


V5200 


989 


c 


V5210 


989 


c 


V5220 


989 


c 


V5230 


989 


c 


V5240 


989 


c 


V5299 


989 


c 


V5336 


989 


c 


V5362 


318 


c 


V5363 


318 


c 


V5364 


318 


c 



194 



Final Report 



APPENDIX F 



Map of ICD-9-CM Diagnosis Codes to 
PCGs 



In Appendix F, in place of the PCG number, a letter may be present. The 
letters mean that the diagnosis code is assigned to multiple PCGs, depending 
on the age or sex of the patient. 



Letter 


PCG 


Condition 


A 


503 


Sex = female 


A 


504 


Sex = male 


B 


303 


Age under 1 8 


B 


304 


Age 1 8 and older 


C 


301 


Age under 1 8 


C 


302 


Age 18 and older 


E 


540 


Age under 18 


E 


542 


Age 18 and older 


F 


560 


Age under 18 


F 


561 


Age 1 8 and older 


G 


663 


Sex = female 


G 


664 


Sex = male 


H 


299 


Age under 1 8 


H 


300 


Age 18 and over 


J 


305 


Age under 1 8 


J 


306 


Age 1 8 and over 


K 


590 


Age under 18 


K 


591 


Age 18 and over 



The Development of a Physician Prospective Payment System for Ambulatory Care 



195 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


0010 


597 


00841 


597 


OHIO 


564 


01191 


563 


01322 


516 


0011 


597 


00842 


597 


01111 


564 


01192 


563 


01323 


516 


0019 


597 


00843 


596 


01112 


564 


01193 


563 


01324 


516 


0020 


502 


00844 


596 


01113 


564 


01194 


563 


01325 


516 


0021 


502 


00845 


596 


01114 


564 


01195 


563 


01326 


516 


0022 


502 


00846 


596 


01115 


564 


01196 


563 


01330 


516 


0023 


502 


00847 


596 


01116 


564 


01200 


564 


01331 


516 


0029 


502 


00849 


597 


01120 


564 


01201 


564 


01332 


516 


0030 


597 


0085 


596 


01121 


564 


01202 


564 


01333 


516 


0031 


502 


00861 


596 


01122 


564 


01203 


564 


01334 


516 


00320 


502 


00862 


596 


01123 


564 


01204 


564 


01335 


516 


00321 


502 


00863 


596 


01124 


564 


01205 


564 


01336 


516 


00322 


564 -' 


00864 


596 


01125 


564 


01206 


564 


01340 


516 


00323 


628 


00865 


596 


01126 


564 


01210 


564 


01341 


516 


00324 


628 


00866 


596 


01130 


564 


01211 


564 


01342 


516 


00329 


502 


00867 


596 


01131 


564 


01212 


564 


01343 


516 


0038 


502 


00869 


596 


01132 


564 


01213 


564 


01344 


516 


0039 


502 


0088 


596 


01133 


564 


01214 


564 


01345 


516 


0040 


597 


0090 


596 


01134 


564 


01215 


564 


01346 


516 


0041 


597 


0091 


596 


01135 


564 


01216 


564 


01350 


516 


0042 


597 


0092 


596 


01136 


564 


01220 


563 


01351 


516 


0043 


597 


0093 


596 


01140 


564 


01221 


563 


01352 


516 


0048 


597 


01000 


564 


01141 


564 


01??? 


563 


01353 


516 


0049 


597 


01001 


564 


01142 


564 


01223 


563 


01354 


516 


0050 


597 


01002 


564 


01143 


564 


01224 


563 


01355 


516 


0051 


502 


01003 


564 


01144 


564 


01225 


563 


01356 


516 


0052 


597 


01004 


564 


01145 


564 


01226 


563 


01360 


516 


0053 


597 


01005 


564 


01146 


564 


01230 


563 


01361 


516 


0054 


597 


01006 


564 


01150 


564 


01231 


563 


01362 


516 


0058 


596 


01010 


564 


01151 


564 


01232 


563 


01363 


516 


00581 


597 


01011 


564 


01152 


564 


01233 


563 


01364 


516 


00589 


597 


01012 


564 


01153 


564 


01234 


563 


01365 


516 


0059 


596 


01013 


564 


01154 


564 


01235 


563 


01366 


516 


0060 


593 


01014 


564 


01155 


564 


01236 


563 


01380 


515 


0061 


596 


01015 


564 


01156 


564 


01280 


563 


01381 


515 


0062 


596 


01016 


564 


01160 


564 


01281 


563 


01382 


515 


0063 


593 


01080 


564 


01161 


564 


01282 


563 


01383 


515 


0064 


564 


01081 


564 


01162 


564 


01283 


563 


01384 


515 


0065 


502 


01082 


564 


01163 


564 


01284 


563 


01385 


515 


0066 


635 


01083 


564 


01164 


564 


01285 


563 


01386 


515 


0068 


501 


01084 


564 


01165 


564 


01286 


563 


01390 


515 


0069 


501 


01085 


564 


01166 


564 


01300 


516 


01391 


515 


0070 


502 


01086 


564 


01170 


564 


01301 


516 


01392 


515 


0071 


596 


01090 


564 


01171 


564 


01302 


516 


01393 


515 


0072 


596 


01091 


564 


01172 


564 


01303 


516 


01394 


515 


0073 


596 


01092 


564 


01173 


564 


01304 


516 


01395 


515 


0078 


596 


01093 


564 


01174 


564 


01305 


516 


01396 


515 


0079 


596 


01094 


564 


01175 


564 


01306 


516 


01400 


597 


00800 


597 


01095 


564 


01176 


564 


01310 


516 


01401 


597 


00801 


597 


010% 


564 


01180 


563 


01311 


516 


01402 


597 


00802 


597 


01100 


564 


01181 


563 


01312 


516 


01403 


597 


00803 


597 


01 101 


564 


01182 


563 


01313 


516 


01404 


597 


00804 


597 


01102 


564 


01183 


563 


01314 


516 


01405 


597 


00809 


597 


01103 


564 


01184 


563 


01315 


516 


01406 


597 


0081 


597 


01104 


564 


01185 


563 


01316 


516 


01480 


597 


0082 


597 


01105 


564 


01186 


563 


01320 


516 


01481 


597 


0083 


597 


01106 


564 


01190 


563 


01321 


516 


01482 


597 


196 


■ 
















Final Report 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


01483 


597 


01594 


628 


01675 


681 


01766 


653 


0220 


635 


01484 


597 


01595 


628 


01676 


681 


01770 


694 


0221 


562 


01485 


597 


01596 


628 


01690 


665 


01771 


694 


0??? 


597 


01486 


597 


01600 


665 


01691 


665 


01772 


694 


0223 


502 


01500 


628 


01601 


665 


01692 


665 


01773 


694 


0228 


502 


01501 


628 


01602 


665 


01693 


665 


01774 


694 


0229 


502 


01502 


628 


01603 


665 


01694 


665 


01775 


694 


0230 


502 


01503 


628 


01604 


665 


01695 


665 


01776 


694 


0231 


502 


01504 


628 


01605 


665 


01696 


665 


01780 


597 


0232 


502 


01505 


628 


01606 


665 


01700 


635 


01781 


597 


0233 


502 


01506 


628 


01610 


665 


01701 


635 


01782 


597 


0238 


502 


01510 


628 . 


01611 


665 


01702 


635 


01783 


597 


0239 


502 


01511 


628 .' 


01612 


665 


01703 


635 


01784 


597 


024 


502 


01512 


628 


01613 


665 


01704 


635 


01785 


597 


025 


502 


01513 


628 


01614 


665 


01705 


635 


01786 


597 


0260 


502 


01514 


628 


01615 


665 


01706 


635 


01790 


502 


0261 


502 


01515 


628 


01616 


665 


01710 


635 


01791 


502 


0269 


502 


01516 


628 


01620 


665 


01711 


635 


01792 


502 


0270 


502 


01520 


628 


01621 


665 


01712 


635 


01793 


502 


0271 


502 


01521 


628 


01622 


665 


01713 


635 


01794 


502 


0272 


502 


01522 


628 


01623 


665 


01714 


635 


01795 


502 


0278 


502 


01523 


628 


01624 


665 


01715 


635 


01796 


502 


0279 


502 


01524 


628 


01625 


665 


01716 


635 


01800 


502 


0300 


502 


01525 


628 


01626 


665 


01720 


694 


01801 


502 


0301 


502 


01526 


628 


01630 


665 


01721 


694 


01802 


502 


0302 


502 


01550 


628 


01631 


665 


01722 


694 


01803 


502 


0303 


502 


01551 


628 


01632 


665 


01723 


694 


01804 


502 


0308 


502 


01552 


628 


01633 


665 


01724 


694 


01805 


502 


0309 


502 


01553 


628 


01634 


665 


01725 


694 


01806 


502 


0310 


564 


01554 


628 


01635 


665 


01726 


694 


01880 


502 


0311 


635 


01555 


628 


01636 


665 


01730 


534 


0188! 


502 


0318 


502 


01556 


628 


01640 


672 


01731 


534 


01882 


502 


0319 


502 


01560 


545 


01641 


672 


01732 


534 


01883 


502 


0320 


545 


01561 


545 


01642 


672 


01733 


534 


01884 


502 


0321 


545 


01562 


545 


01643 


672 


01734 


534 


01885 


502 


0322 


545 


01563 


545 


01644 


672 


01735 


534 


01886 


502 


0323 


545 


01564 


545 


01645 


672 


01736 


534 


01890 


502 


03281 


534 


01565 


545 


01646 


672 


01740 


545 


01891 


502 


03282 


576 


01566 


545 


01650 


672 


01741 


545 


01892 


502 


03283 


597 


01570 


628 


01651 


672 


01742 


545 


01893 


502 


03284 


665 


01571 


628 


01652 


672 


01743 


545 


01894 


502 


03285 


635 


01572 


628 


01653 


672 


01744 


545 


01895 


502 


03289 


502 


01573 


628 


01654 


672 


01745 


545 


01896 


502 


0329 


502 


01574 


628 


01655 


672 


01746 


545 


0200 


502 


0330 


564 


01575 


628 


01656 


672 


01750 


653 


0201 


502 


0331 


564 


01576 


628 


01660 


681 


01751 


653 


0202 


502 


0338 


564 


01580 


628 


01661 


681 


01752 


653 


0203 


564 


0339 


564 


01581 


628 


01662 


681 


01753 


653 


0204 


564 


0340 


E 


01582 


628 


01663 


681 


01754 


653 


0205 


564 


0341 


501 


01583 


628 


01664 


681 


01755 


653 


0208 


502 


035 


635 


01584 


628 


01665 


681 


01756 


653 


0209 


502 


0360 


516 


01585 


628 


01666 


681 


01760 


653 


0210 


502 


0361 


516 


01586 


628 


01670 


681 


01761 


653 


0211 


597 


0362 


502 


01590 


628 


01671 


681 


01762 


653 


0212 


564 


0363 


502 


01591 


628 


01672 


681 


01763 


653 


0213 


502 


03640 


576 


01592 


628 


01673 


681 


01764 


653 


0218 


502 


03641 


576 


01593 


628 


01674 


681 


01765 


653 


0219 


502 


03642 


576 



The Development of a Physician Prospective Payment System for Ambulatory Care 



197 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


03643 


576 


0421 


691 


05312 


515 


0623 


516 


0737 


501 


03681 


534 


0422 


691 


05313 


515 


0624 


516 


0738 


501 


03682 


628 


0429 


691 


05319 


515 


0625 


516 


0739 


501 


03689 


502 


0430 


691 


05320 


534 


0628 


516 


0740 


E 


0369 


501 


0431 


691 


05321 


534 


0629 


516 


0741 


564 


037 


502 


0432 


694 


05322 


534 


0630 


516 


07420 


576 


0380 


502 


0433 


691 


05329 


534 


0631 


502 


07421 


576 


0381 


502 


0439 


691 


05371 


E 


0632 


516 


07422 


576 


0382 


502 


0440 


691 


05379 


501 


0638 


516 


07423 


576 


0383 


502 


0449 


691 


0538 


501 


0639 


516 


0743 


501 


03840 


502 


04500 


516 


0539 


635 


064 


515 


0748 


501 


03841 


502 . 


04501 


516 


0540 


635 


0650 


502 


075 


501 


03842 


502 . ■ 


04502 


516 


05410 


A 


0651 


502 


0760 


534 


03843 


502 


04503 


516 


05411 


A 


0652 


502 


0761 


534 


03844 


502 


04510 


516 


05412 


A 


0653 


502 


0769 


534 


03849 


502 


04511 


516 


05413 


A 


0654 


502 


0770 


533 


0388 


502 


04512 


516 


05419 


A 


0658 


502 


0771 


533 


0389 


502 


04513 


516 


0542 


E 


0659 


502 


0772 


533 


0390 


635 


04520 


516 


0543 


516 


0660 


502 


0773 


533 


0391 


564 


04521 


516 


05440 


534 


0661 


502 


0774 


533 


0392 


597 


04522 


516 


05441 


534 


0662 


516 


0778 


533 


0393 


635 


04523 


516 


05442 


534 


0663 


502 


0779 


533 


0394 


635 


04590 


516 


05443 


534 


0668 


502 


07798 


501 


0398 


502 


04591 


516 


05444 


534 


0669 


502 


07799 


501 


0399 


502 


04592 


516 


05449 


534 


0700 


611 


0780 


635 


0400 


502 


04593 


516 


0545 


502 


0701 


593 


0781 


635 


0401 


502 


0460 


516 


0546 


635 


07020 


611 


07810 


A 


0402 


597 


0461 


516 


05471 


597 


07021 


611 


07811 


A 


0403 


502 


0462 


516 


05472 


516 


07022 


611 


07819 


A 


04081 


628 


0463 


516 


05473 


E 


07023 


611 


0782 


501 


04089 


501 


0468 


516 


05479 


501 


07030 


593 


0783 


502 


04100 


501 


0469 


516 


0548 


501 


07031 


593 


0784 


501 


04101 


501 


0470 


516 


0549 


635 


07032 


5% 


0785 


502 


04102 


501 


0471 


516 


0550 


516 


07033 


596 


0786 


665 


04103 


501 


0478 


516 


0551 


562 


07041 


611 


0787 


502 


04104 


501 


0479 


516 


0552 


E 


07042 


611 


07881 


545 


04105 


501 


048 


516 


05571 


534 


07043 


611 


07882 


597 


04109 


501 


0490 


516 


05579 


501 


07044 


611 


07888 


A 


04110 


501 


0491 


516 


0558 


501 


07049 


611 


07889 


501 


04111 


501 


0498 


516 


0559 


501 


07051 


593 


0790 


501 


04119 


501 


0499 


516 


05600 


515 


07052 


593 


0791 


501 


0412 


501 


OSOO 


502 


05601 


516 


07053 


593 


0792 


501 


0413 


501 


0301 


502 


05609 


516 


07054 


596 


0793 


501 


0414 


501 


0502 


502 


05671 


628 


07059 


593 


0794 


A 


0415 


501 


0509 


502 


05679 


501 


0706 


611 


07950 


691 


0416 


501 


0510 


502 


0568 


501 


0709 


593 


07951 


691 


0417 


501 


0511 


635 


0569 


501 


071 


516 


07952 


691 


04181 


501 


0512 


635 


0570 


501 


0720 


672 


07953 


691 


04182 


501 


0519 


501 


0578 


501 


0721 


516 


07959 


691 


04183 


502 


0520 


515 


0579 


501 


0722 


516 


0798 


A 


04184 


502 


0521 


562 


0600 


501 


0723 


593 


07981 


502 


04185 


501 


0527 


501 


0601 


502 


07271 


593 


07988 


501 


04186 


592 


0528 


501 


0609 


502 


07272 


515 


07989 


501 


04189 


501 


0529 


501 


061 


502 


07279 


501 


0799 


501 


0419 


501 


0530 


516 


0620 


516 


0728 


501 


07998 


501 


042 


691 


05310 


515 


0621 


516 


0729 


50! 


07999 


501 


0420 


691 


05311 


515 


0622 


516 


0730 


562 


080 


502 


198 


















Final Report 



^p. 















Map of ICD-9-CM 


Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


0810 


502 


0907 


A 


0979 


A 


1000 


501 


1149 


502 


0811 


502 


0909 


A 


0980 


A 


10081 


516 


11500 


502 


0812 


502 


0910 


A 


09810 


A 


10089 


515 


11501 


516 


0819 


502 


0911 


596 


09811 


661 


1009 


501 


11502 


534 


0820 


502 


0912 


A 


09812 


672 


101 


545 


11503 


576 


0821 


502 


0913 


635 


09813 


A 


1020 


635 


11504 


576 


0822 


502 


0914 


501 


09814 


A 


1021 


635 


11505 


564 


0823 


502 


09150 


533 


09815 


A 


1022 


635 


11509 


502 


0828 


502 


09151 


533 


09816 


A 


1023 


635 


11510 


502 


0829 


502 


09152 


533 


09817 


A 


1024 


635 


11511 


516 


0830 


502 


09161 


628 


09819 


A 


1025 


545 


11512 


534 


0831 


502 ^ 


09162 


593 


0982 


A 


1026 


628 


11513 


576 


0832 


502 . ' 


09169 


597 


09830 


665 


1027 


501 


11514 


576 


0838 


502 


0917 


A 


09831 


661 


1028 


501 


11515 


564 


0839 


502 


09181 


516 


09832 


672 


1029 


501 


11519 


502 


0840 


502 


09182 


635 


09833 


A 


1030 


635 


11590 


502 


0841 


502 


09189 


A 


09834 


A 


1031 


635 


11591 


516 


0842 


502 


0919 


A 


09835 


A 


1032 


A 


11592 


534 


0843 


502 


0920 


A 


09836 


A 


1033 


635 


11593 


576 


0844 


502 


0929 


A 


09837 


A 


1039 


A 


11594 


576 


0845 


502 


0930 


576 


09839 


A 


1040 


A 


11595 


564 


0846 


502 


0931 


576 


09840 


533 


1048 


A 


11599 


502 


0847 


502 


09320 


576 


09841 


534 


1049 


A 


1160 


502 


0848 


502 


09321 


576 


09842 


534 


1100 


635 


1161 


502 


0849 


502 


09322 


576 


09843 


534 


1101 


631 


1162 


502 


0850 


502 


09323 


576 


09849 


534 


1102 


635 


1170 


502 


0851 


635 


09324 


576 


09850 


628 


1103 


635 


1171 


502 


0852 


635 


09381 


576 


09851 


628 


1104 


635 


1172 


502 


0853 


635 


09382 


576 


09852 


628 


1105 


635 


1173 


502 


0854 


635 


09389 


576 


09853 


628 


1106 


635 


1174 


502 


0855 


635 


0939 


576 


09859 


628 


1108 


635 


1175 


502 


0859 


501 


0940 


515 


0986 


E 


1109 


635 


1176 


502 


0860 


576 


0941 


515 


0987 


A 


1110 


635 


1177 


502 


0861 


502 


0942 


516 


09881 


534 


1111 


635 


1178 


501 


0862 


502 


0943 


515 


09882 


516 


1112 


635 


1179 


635 


0863 


502 


09481 


516 


09883 


576 


1113 


635 


118 


501 


0864 


502 


09482 


516 


09884 


576 


1118 


635 


1200 


665 


0865 


502 


09483 


533 


09885 


576 


1119 


635 


1201 


593 


0869 


502 


09484 


533 


09886 


597 


1120 


E 


1202 


502 


0870 


502 


09485 


515 


09889 


A 


1121 


A 


1203 


635 


0871 


502 


09486 


545 


0990 


A 


1122 


A 


1208 


5(K 


0879 


502 


09487 


516 


0991 


A 


1123 


635 


1209 


502 


0880 


502 


09489 


515 


0992 


A 


1124 


564 


1210 


593 


08881 


502 


0949 


515 


0993 


628 


1125 


502 


1211 


593 


08882 


502 


0950 


533 


09940 


A 


11281 


576 


1212 


564 


08889 


502 


0951 


564 


09941 


A 


11282 


544 


1213 


593 


0889 


501 


0952 


597 


09949 


A 


11283 


515 


1214 


593 


0900 


501 


0953 


593 


09950 


A 


11284 


501 


1215 


502 


0901 


A 


0954 


665 


09951 


A 


11285 


501 


1216 


502 


0902 


A 


0955 


628 


09952 


A 


11289 


501 


1218 


502 


0903 


533 


0956 


628 


09953 


A 


1129 


635 


1219 


502 


09040 


515 


0957 


628 


09954 


A 


1140 


564 


1220 


593 


09041 


515 


0958 


A 


09955 


A 


1141 


635 


1221 


564 


09042 


515 


0959 


A 


09956 


A 


1142 


516 


1222 


653 


09049 


515 


096 


A 


09959 


A 


1143 


502 


1773 


502 


0905 


A 


0970 


A 


0998 


A 


1144 


502 


1224 


502 


0906 


A 


0971 


A 


0999 


A 


1145 


502 


1225 


593 



The Development of a Physician Prospective Payment System for Ambulatory Care 



199 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


1226 


502 


13109 


A 


1431 


437 


1518 


435 


1618 


437 


1227 


502 


1318 


A 


1438 


437 


1519 


435 


1619 


437 


1228 


593 


1319 


A 


1439 


437 


1520 


435 


1620 


433 


1229 


502 


1320 


635 


1440 


437 


1521 


435 


1622 


433 


1230 


597 


1321 


635 


1441 


437 


1522 


435 


1623 


433 


1231 


597 


1322 


635 


1448 


437 


1523 


435 


1624 


433 


1232 


597 


1323 


635 


1449 


437 


1S28 


435 


1625 


433 


1233 


597 


1329 


635 


1450 


437 


1529 


435 


1628 


433 


1234 


597 


1330 


635 


1451 


437 


1530 


435 


1629 


433 


1235 


597 


1338 


501 


1452 


437 


1531 


435 


1630 


433 


1236 


597 


1339 


SOI 


1453 


437 


1532 


435 


1631 


433 


1238 


597 . 


1340 


501 


1454 


437 


1533 


435 


1638 


433 


1239 


597 . ■ 


1341 


635 


1455 


437 


1534 


435 


1639 


433 


124 


502 


1342 


635 


1456 


437 


1535 


435 


1640 


437 


1250 


502 


1348 


635 


1458 


437 


1536 


435 


1641 


437 


1251 


502 


1349 


635 


1459 


437 


1537 


435 


1642 


437 


1252 


502 


135 


563 


1460 


437 


1538 


435 


1643 


437 


1253 


502 


1360 


501 


1461 


437 


1539 


435 


1648 


437 


1254 


502 


1361 


628 


1462 


437 


1540 


435 


1649 


437 


1255 


502 


1362 


501 


1463 


437 


1541 


435 


1650 


433 


1256 


502 


1363 


564 


1464 


437 


1542 


435 


1658 


433 


1257 


502 


1364 


502 


1465 


437 


1543 


435 


1659 


433 


1259 


502 


1365 


502 


1466 


437 


1548 


435 


1700 


437 


1260 


597 


1368 


501 


1467 


437 


1550 


435 


1701 


437 


1261 


597 


1369 


501 


1468 


437 


1551 


435 


1702 


437 


1262 


597 


1370 


564 


1469 


437 


1552 


435 


1703 


437 


1263 


597 


1371 


515 


1470 


437 


1560 


435 


1704 


437 


1268 


597 


1372 


G 


1471 


437 


1S61 


435 


1705 


437 


1269 


597 


1373 


622 


1472 


437 


1562 


435 


1706 


437 


1270 


597 


1374 


501 


1473 


437 


1S68 


435 


1707 


437 


1271 


597 


138 


515 


1478 


437 


1569 


435 


1708 


437 


1272 


597 


1390 


515 


1479 


437 


1570 


435 


1709 


437 


1273 


597 


1391 


534 


1480 


437 


1571 


435 


1710 


437 


1274 


597 


1398 


501 


1481 


437 


1572 


435 


1712 


437 


1275 


597 


1400 


436 


1482 


437 


1573 


435 


1713 


437 


1276 


597 


1401 


436 


1483 


437 


1574 


435 


1714 


437 


1277 


597 


1403 


437 


1488 


437 


1578 


435 


1715 


437 


1278 


502 


1404 


437 


1489 


437 


1579 


435 


1716 


437 


1279 


597 


1405 


437 


1490 


437 


1580 


435 


1717 


436 


1280 


502 


1406 


436 


1491 


437 


1588 


435 


1718 


436 


1281 


502 


1408 


436 


1498 


437 


1589 


435 


1719 


436 


1288 


502 


1409 


436 


1499 


437 


1590 


435 


1720 


436 


1289 


502 


1410 


437 


1500 


435 


1591 


435 


1721 


436 


129 


597 


1411 


437 


1501 


435 


1598 


435 


1722 


436 


1300 


515 


1412 


437 


1502 


435 


1599 


435 


1723 


436 


1301 


534 


1413 


437 


1503 


435 


1600 


437 


1724 


436 


1302 


534 


1414 


437 


1504 


435 


1601 


437 


1725 


436 


1303 


576 


1415 


437 


1505 


435 


1602 


437 


1726 


436 


1304 


564 


1416 


437 


1508 


435 


1603 


437 


1727 


436 


1305 


593 


1418 


437 


1509 


435 


1604 


437 


1728 


436 


1307 


502 


1419 


437 


1510 


435 


1605 


437 


1729 


436 


1308 


502 


1420 


437 


1511 


435 


1608 


437 


1730 


436 


1309 


502 


1421 


437 


1512 


435 


1609 


437 


1731 


436 


13100 


A 


1422 


437 


1513 


435 


1610 


437 


1732 


436 


13101 


A 


1428 


437 


1514 


435 


1611 


437 


1733 


436 


13102 


A 


1429 


437 


1515 


435 


1612 


437 


1734 


436 


13103 


A 


1430 


437 


1516 


435 


1613 


437 


1735 


436 


200 


















Final Report 















Map of ICD-9-CM 


Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


1736 


436 


1879 


437 


1954 


437 


20026 


431 


20160 


431 


1737 


436 


1880 


437 


1955 


437 


20027 


431 


20161 


431 


1738 


436 


1881 


437 


1958 


431 


20028 


431 


20162 


431 


1739 


436 


1882 


437 


1960 


431 


20080 


431 


20163 


431 


1740 


434 


1883 


437 


1961 


431 


20081 


431 


20164 


431 


1741 


434 


1884 


437 


1962 


431 


20082 


431 


20165 


431 


1742 


434 


1885 


437 


1963 


431 


20083 


431 


20166 


431 


1743 


434 


1886 


437 


1965 


431 


20084 


431 


20167 


431 


1744 


434 


1887 


437 


1966 


431 


20085 


431 


20168 


431 


1745 


434 


1888 


437 


1968 


431 


20086 


431 


20170 


431 


1746 


434 


1889 


437 


1969 


431 


20087 


431 


20171 


431 


1748 


434 . 


1890 


437 


1970 


433 


20088 


431 


20172 


431 


1749 


434 , " 


1891 


437 


1971 


437 


20100 


431 


20173 


431 


1750 


434 


1892 


437 


1972 


433 


20101 


431 


20174 


431 


1759 


434 


1893 


437 


1973 


433 


20102 


431 


20175 


431 


1760 


691 


1894 


437 


1974 


437 


20103 


431 


20176 


431 


1761 


691 


1898 


437 


1975 


437 


20104 


431 


20177 


431 


1762 


691 


1899 


437 


1976 


437 


20105 


431 


20178 


431 


1763 


691 


1900 


437 


1977 


437 


20106 


431 


20190 


431 


1764 


691 


1901 


437 


1978 


437 


20107 


431 


20191 


431 


1765 


691 


1902 


437 


1980 


437 


20108 


431 


20192 


431 


1768 


691 


1903 


437 


1981 


437 


20110 


431 


20193 


431 


1769 


691 


1904 


437 


1982 


436 


20111 


431 


20194 


431 


179 


437 


1905 


437 


1983 


437 


20112 


431 


20195 


431 


1800 


437 


1906 


437 


1984 


437 


20113 


431 


20196 


431 


1801 


437 


1907 


437 


1985 


437 


20114 


431 


20197 


431 


1808 


437 


1908 


437 


1986 


437 


20115 


431 


20198 


431 


1809 


437 


1909 


437 


1987 


437 


20116 


431 


20200 


431 


181 


437 


1910 


437 


19881 


437 


20117 


431 


20201 


431 


1820 


437 


1911 


437 


19882 


437 


20118 


431 


20202 


431 


1821 


437 


1912 


437 


19889 


437 


20120 


431 


20203 


431 


1828 


437 


1913 


437 


1990 


437 


20121 


431 


20204 


431 


1830 


437 


1914 


437 


1991 


437 


20122 


431 


20205 


431 


1832 


437 


1915 


437 


20000 


431 


20123 


431 


20206 


431 


1833 


437 


1916 


437 


20001 


431 


20124 


431 


20207 


431 


1834 


437 


1917 


437 


20002 


431 


20125 


431 


20208 


431 


1835 


437 


1918 


437 


20003 


431 


20126 


431 


20210 


431 


1838 


437 


1919 


437 


20004 


431 


20127 


431 


20211 


431 


1839 


437 


1920 


437 


20005 


431 


20128 


431 


20212 


431 


1840 


437 


1921 


437 


20006 


431 


20140 


431 


20213 


431 


1841 


437 


1922 


437 


20007 


431 


20141 


431 


20214 


431 


1842 


437 


1923 


437 


20008 


431 


20142 


431 


20215 


431 


1843 


437 


1928 


437 


20010 


431 


20143 


431 


20216 


431 


1844 


437 


1929 


437 


20011 


431 


20144 


431 


20217 


431 


1848 


437 


193 


437 


20012 


431 


20145 


431 


20218 


431 


1849 


437 


1940 


437 


20013 


431 


20146 


431 


20220 


431 


185 


432 


1941 


437 


20014 


431 


20147 


431 


20221 


431 


1860 


437 


1943 


437 


20015 


431 


20148 


431 


20222 


431 


1869 


437 


1944 


437 


20016 


431 


20150 


431 


20223 


431 


1871 


437 


1945 


437 


20017 


431 


20151 


431 


20224 


431 


1872 


437 


1946 


437 


20018 


431 


20152 


431 


20225 


431 


1873 


437 


1948 


437 


20020 


431 


20153 


431 


20226 


431 


1874 


437 


1949 


437 


20021 


431 


20154 


431 


20227 


431 


1875 


437 


1950 


437 


20022 


431 


20155 


431 


20228 


431 


1876 


437 


1951 


437 


20023 


431 


20156 


431 


20230 


431 


1877 


437 


1952 


437 


20024 


431 


20157 


431 


20231 


431 


1878 


437 


1953 


437 


20025 


431 


20158 


431 


20232 


431 



The Development of a Physician Prospective Payment System for Ambulatory Care 



201 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


20233 


431 


20400 


431 


2107 


544 


2168 


635 


22800 


575 


20234 


431 


20401 


431 


2108 


544 


2169 


635 


22801 


635 


20235 


431 


20410 


431 


2109 


544 


217 


635 


22802 


516 


20236 


431 


20411 


431 


2110 


596 


2180 


681 


22803 


534 


20237 


431 


20420 


431 


2111 


597 


2181 


681 


22804 


596 


20238 


431 


20421 


431 


2112 


597 


2182 


681 


22809 


575 


20240 


431 


20480 


431 


2113 


597 


2189 


681 


2281 


694 


20241 


431 


20481 


431 


2114 


597 


2190 


681 


2290 


693 


20242 


431 


20490 


431 


2115 


593 


2191 


681 


2298 


635 


7fl743 


431 


20491 


431 


2116 


593 


2198 


681 


2299 


635 


20244 


431 


20500 


431 


2117 


652 


2199 


681 


2300 


596 


20245 


431 . 


20501 


431 


2118 


596 


220 


681 


2301 


596 


20246 


431 . ■ 


20510 


431 


2119 


596 


2210 


681 


2302 


5% 


20247 


431 


20511 


431 


2120 


544 


2211 


681 


2303 


596 


20248 


431 


20520 


431 


2121 


544 


2212 


681 


2304 


596 


m250 


431 


20521 


431 


2122 


563 


2218 


681 


2305 


596 


20251 


431 


20530 


431 


2123 


564 


2219 


681 


2306 


596 


20252 


431 


20531 


431 


2124 


564 


2220 


672 


2307 


5% 


20253 


431 


20580 


431 


2125 


564 


2221 


672 


2308 


596 


20254 


431 


20581 


431 


2126 


694 


??•'? 


672 


2309 


596 


20255 


431 


20590 


431 


2127 


576 


2223 


672 


2310 


563 


20256 


431 


20591 


431 


2128 


564 


2224 


672 


2311 


563 


20257 


431 


20600 


431 


2129 


564 


2228 


672 


2312 


563 


20258 


431 


20601 


431 


2130 


622 


2229 


672 


2318 


563 


20260 


431 


20610 


431 


2131 


544 


2230 


G 


2319 


563 


20261 


431 


20611 


431 


2132 


622 


2231 


G 


2320 


635 


20262 


431 


20620 


431 


2133 


564 


2232 


G 


2321 


635 


20263 


431 


20621 


431 


2134 


622 


2233 


G 


2322 


635 


20264 


431 


20680 


431 


2135 


622 


22381 


G 


2323 


635 


20265 


431 


20681 


431 


2136 


622 


22389 


G 


2324 


635 


20266 


431 


20690 


431 


2137 


622 


2239 


G 


2325 


635 


20267 


431 


20691 


431 


2138 


622 


2240 


534 


2326 


635 


20268 


431 


20700 


431 


2139 


622 


2241 


534 


2327 


635 


20280 


431 


20701 


431 


2140 


635 


2242 


534 


2328 


635 


20281 


431 


20710 


431 


2141 


635 


2243 


534 


2329 


635 


20282 


431 


20711 


431 


2142 


563 


2244 


534 


2330 


634 


20283 


431 


20720 


431 


2143 


596 


2245 


534 


2331 


681 


20284 


431 


20721 


431 


2144 


672 


2246 


534 


2332 


681 


20285 


431 


20780 


431 


2148 


635 


2247 


534 


2333 


681 


20286 


431 


20781 


431 


2149 


635 


2248 


534 


2334 


432 


20287 


431 


20800 


431 


2150 


635 


2249 


534 


2335 


672 


20288 


431 


20801 


431 


2152 


635 


2250 


515 


2336 


672 


20290 


431 


20810 


431 


2153 


635 


2251 


516 


2337 


G 


20291 


431 


20811 


431 


2154 


635 


2252 


516 


2339 


G 


20292 


431 


20820 


431 


2155 


635 


2253 


515 


2340 


534 


20293 


431 


20821 


431 


2156 


635 


2254 


515 


2348 


635 


20294 


431 


20880 


431 


2157 


635 


2258 


515 


2349 


635 


20295 


431 


20881 


431 


2158 


635 


2259 


515 


2350 


437 


20296 


431 


20890 


431 


2159 


635 


226 


652 


2351 


437 


20297 


431 


20891 


431 


2160 


635 


2270 


653 


2352 


435 


20298 


431 


2100 


544 


2161 


534 


2271 


653 


2353 


435 


20300 


431 


2101 


544 


2162 


635 


2273 


653 


2354 


435 


20301 


431 


2102 


544 


2163 


635 


2274 


515 


2355 


435 


20310 


431 


2103 


544 


2164 


635 


2275 


515 


2356 


437 


20311 


431 


2104 


544 


2165 


635 


2276 


515 


2357 


433 


20380 


431 


2105 


544 


2166 


635 


2278 


652 


2358 


433 


20381 


431 


2106 


544 


2167 


635 


2279 


652 


2359 


433 


202 


















Final Report 



: <t!4^ 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


2360 


437 


24280 


653 


25081 


650 


2589 


653 


2713 


596 


2361 


437 


24281 


611 


25082 


650 


2590 


653 


2714 


652 


2362 


437 


24290 


652 


25083 


650 


2591 


653 


2718 


652 


2363 


437 


24291 


611 


25090 


650 


2592 


653 


2719 


652 


2364 


437 


243 


652 


25091 


650 


2593 


653 


2720 


652 


2365 


432 


2440 


652 


25092 


650 


2594 


653 


2721 


652 


2366 


437 


2441 


652 


25093 


650 


2598 


652 


2722 


652 


2367 


437 


2442 


652 


2510 


611 


2599 


652 


2723 


652 


23690 


437 


2443 


652 


2511 


653 


260 


653 


2724 


652 


23691 


437 


2448 


652 


2512 


653 


261 


653 


2725 


652 


23699 


437 


2449 


652 


2513 


653 


262 


653 


2726 


652 


2370 


437 ^ 


2450 


653 


2514 


653 


2630 


652 


2727 


653 


2371 


437 . ' 


2451 


652 


2515 


596 


2631 


652 


2728 


652 


2372 


437 


2452 


653 


2518 


652 


2632 


653 


2729 


652 


2373 


437 


2453 


652 


2519 


652 


2638 


653 


2730 


694 


2374 


437 


2454 


652 


2520 


652 


2639 


653 


2731 


694 


2375 


437 


2458 


652 


2521 


652 


2640 


534 


2732 


431 


2376 


437 


2459 


652 


2528 


652 


2641 


534 


2733 


431 


23770 


516 


2460 


652 


2529 


652 


2642 


534 


2738 


431 


23771 


516 


2461 


652 


2530 


653 


2643 


534 


2739 


431 


23772 


516 


2462 


652 


2531 


653 


2644 


534 


2740 


622 


2379 


437 


2463 


652 


2532 


653 


2645 


534 


27410 


G 


2380 


437 


2468 


652 


2533 


653 


2646 


534 


27411 


G 


2381 


437 


2469 


652 


2534 


653 


2647 


534 


27419 


G 


2382 


436 


25000 


650 


2535 


653 


2648 


652 


27481 


622 


2383 


434 


25001 


650 


2536 


653 


2649 


652 


27482 


622 


2384 


431 


25002 


650 


2537 


653 


2650 


653 


27489 


622 


2385 


431 


25003 


650 


2538 


653 


2651 


652 


2749 


622 


2386 


431 


25010 


611 


2539 


653 


2652 


653 


2750 


652 


2387 


431 


25011 


611 


2540 


693 


2660 


652 


2751 


652 


2388 


437 


25012 


611 


2541 


694 


2661 


652 


2752 


653 


2389 


437 


25013 


611 


2548 


694 


?66? 


652 


2753 


653 


2390 


435 


25020 


611 


2549 


694 


2669 


652 


2754 


653 


2391 


433 


25021 


611 


2550 


653 


267 


653 


2758 


652 


2392 


437 


25022 


611 


2551 


653 


2680 


628 


2759 


652 


2393 


434 


25023 


611 


2552 


653 


2681 


628 


2760 


654 


2394 


437 


25030 


611 


2553 


653 


2682 


628 


2761 


654 


2395 


437 


25031 


611 


2554 


653 


2689 


652 


2762 


654 


2396 


437 


25032 


611 


2555 


653 


2690 


653 


2763 


654 


2397 


437 


25033 


611 


2556 


653 


2691 


652 


2764 


654 


2398 


437 


25040 


651 


2558 


653 


2692 


652 


2765 


654 


2399 


437 


25041 


651 


2559 


653 


2693 


652 


2766 


654 


2400 


652 


25042 


651 


2560 


681 


2698 


652 


2767 


654 


2409 


652 


25043 


651 


2561 


681 


2699 


652 


2768 


654 


2410 


652 


25050 


650 


2562 


681 


2700 


653 


2769 


652 


2411 


652 


25051 


650 


2563 


681 


2701 


653 


27700 


653 


2419 


652 


25052 


650 


2564 


681 


2702 


653 


27701 


481 


24200 


652 


25053 


650 


2568 


681 


2703 


653 


2771 


653 


24201 


611 


25060 


651 


2569 


681 


2704 


653 


2T72 


653 


24210 


652 


25061 


651 


2570 


652 


2705 


653 


2773 


694 


24211 


611 


25062 


651 


2571 


652 


2706 


653 


2774 


593 


24220 


652 


25063 


651 


2572 


652 


2707 


653 


2775 


653 


24221 


611 


25070 


651 


2578 


652 


2708 


653 


2776 


653 


24230 


652 


25071 


651 


2579 


652 


2709 


653 


2778 


652 


24231 


611 


25072 


651 


2580 


653 


2710 


653 


2779 


652 


24240 


653 


25073 


651 


2581 


653 


2711 


653 


2780 


652 


24241 


611 


25080 


650 


2588 


653 


2712 


596 


27800 


652 



The Development of a Physician Prospective Payment System for Ambulatory Care 



203 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


27801 


652 


2848 


692 


2912 


H 


29550 


C 


29636 


C 


2781 


652 


2849 


692 


2913 


H 


29551 


c 


29640 


C 


2782 


652 


2850 


692 


2914 


H 


29552 


c 


29641 


c 


2783 


652 


2851 


692 


2915 


H 


29553 


c 


29642 


C 


2784 


652 


2858 


692 


2918 


H 


29554 


c 


29643 


c 


2788 


652 


2859 


692 


2919 


H 


29555 


c 


29644 


c 


27900 


694 


2860 


694 


2920 


H 


29560 


c 


29645 


C 


27901 


694 


2861 


694 


29211 


H 


29561 


c 


29646 


C 


27902 


694 


2862 


694 


29212 


H 


29562 


c 


29650 


c 


27903 


694 


2863 


694 


2922 


H 


29563 


c 


29651 


C 


27904 


694 


2864 


694 


29281 


H 


29564 


c 


29652 


C 


27905 


694 . 


2865 


694 


29282 


H 


29565 


c 


29653 


C 


27906 


694." 


2866 


694 


29283 


H 


29570 


c 


29654 


C 


27909 


694 


2867 


693 


29284 


H 


29571 


c 


29655 


c 


27910 


694 


2869 


693 


29289 


H 


29572 


c 


29656 


C 


27911 


694 


2870 


693 


2929 


H 


29573 


C 


29660 


c 


27912 


694 


2871 


694 


2930 


296 


29574 


c 


29661 


C 


27913 


694 


2872 


693 


2931 


296 


29575 


C 


29662 


C 


27919 


694 


2873 


694 


29381 


2% 


29580 


c 


29663 


C 


2792 


694 


2874 


694 


29382 


296 


29581 


c 


29664 


C 


2793 


694 


2875 


694 


29383 


2% 


29582 


c 


29665 


C 


2794 


628 


2878 


693 


29389 


296 


29583 


c 


29666 


c 


2798 


694 


2879 


693 


2939 


296 


29584 


c 


2967 


C 


2799 


694 


2880 


694 


2940 


296 


29585 


C 


29680 


c 


2800 


692 


2881 


694 


2941 


296 


29590 


c 


29681 


C 


2801 


692 


2882 


694 


2948 


296 


29591 


c 


29682 


c 


2808 


692 


2883 


694 


2949 


296 


29592 


c 


29689 


C 


2809 


692 


2888 


693 


29500 


C 


29593 


c 


29690 


C 


2810 


692 


2889 


693 


29501 


C 


29594 


c 


29699 


c 


2811 


692 


2890 


693 


29502 


C 


29595 


C 


2970 


c 


2812 


692 


2891 


693 


29503 


C 


29600 


c 


2971 


C 


2813 


692 


2892 


694 


29504 


C 


29601 


c 


2972 


C 


2814 


692 


2893 


693 


29505 


C 


29602 


c 


2973 


c 


2818 


692 


2894 


694 


29510 


C 


29603 


c 


2978 


c 


2819 


692 


28950 


693 


29511 


C 


29604 


c 


2979 


c 


2820 


692 


28951 


694 


29512 


C 


29605 


c 


2980 


C 


2821 


692 


28959 


694 


29513 


C 


29606 


c 


2981 


c 


2822 


694 


2896 


694 


29514 


C 


29610 


c 


2982 


c 


2823 


692 


2897 


694 


29515 


C 


29611 


C 


2983 


C 


2824 


694 


2898 


693 


29520 


C 


29612 


C 


2984 


C 


2825 


692 


2899 


693 


29521 


C 


29613 


C 


2988 


C 


28260 


692 


2900 


296 


29522 


C 


29614 


c 


2989 


C 


28261 


692 


29010 


296 


29523 


C 


29615 


c 


29900 


C 


28262 


694 


29011 


296 


29524 


C 


29616 


c 


29901 


c 


28263 


692 


29012 


296 


29525 


C 


29620 


c 


29910 


c 


28269 


692 


29013 


296 


29530 


C 


29621 


c 


29911 


c 


2827 


694 


29020 


296 


29531 


C 


29622 


C 


29980 


c 


2828 


692 


29021 


296 


29532 


C 


29623 


c 


29981 


c 


2829 


692 


2903 


296 


29533 


C 


29624 


C 


29990 


c 


2830 


692 


29040 


296 


29534 


c 


29625 


c 


29991 


c 


2831 


692 


29041 


296 


29535 


c 


29626 


C 


30000 


B 


28310 


692 


29042 


296 


29540 


c 


29630 


C 


30001 


B 


28311 


692 


29043 


296 


29541 


c 


29631 


c 


30002 


B 


28319 


692 


2908 


296 


29542 


c 


29632 


c 


30009 


B 


2832 


692 


2909 


296 


29543 


c 


29633 


c 


30010 


c 


2839 


692 


2910 


H 


29544 


c 


29634 


c 


30011 


c 


2840 


692 


2911 


H 


29545 


c 


29635 


c 


30012 


c 


204 


















Final Report 



o 















Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


30013 


C 


30281 


C 


30502 


H 


30722 


515 


31211 


C 


30014 


c 


30282 


c 


30503 


H 


30723 


516 


31212 


C 


30015 


c 


30283 


c 


3051 


705 


3073 


C 


31213 


c 


30016 


c 


30284 


c 


30510 


705 


30740 


B 


31220 


C 


30019 


c 


30285 


c 


30511 


705 


30741 


B 


31221 


c 


30020 


c 


30289 


c 


30512 


705 


30742 


B 


31222 


c 


30021 


c 


3029 


c 


30513 


705 


30743 


B 


31223 


c 


30022 


c 


30300 


H 


30520 


H 


30744 


B 


31230 


C 


30023 


c 


30301 


H 


30521 


H 


30745 


B 


31231 


C 


30029 


c 


30302 


H 


30522 


H 


30746 


B 


31232 


C 


3003 


c 


30303 


H 


30523 


H 


30747 


B 


31233 


C 


3004 


B . 


30390 


H 


30530 


H 


30748 


B 


31234 


C 


3005 


B 


30391 


H 


30531 


H 


30749 


B 


31235 


c 


3006 


B 


30392 


H 


30532 


H 


30750 


B 


31239 


c 


3007 


C 


30393 


H 


30533 


H 


30751 


B 


3124 


C 


30081 


c 


30400 


H 


30540 


H 


30752 


B 


3128 


C 


30089 


c 


30401 


H 


30541 


H 


30753 


B 


31281 


515 


3009 


c 


30402 


H 


30542 


H 


30754 


B 


31282 


515 


3010 


c 


30403 


H 


30543 


H 


30759 


B 


31289 


515 


30110 


c 


30410 


H 


30550 


H 


3076 


B 


3129 


C 


30111 


c 


30411 


H 


30551 


H 


3077 


B 


3130 


B 


30112 


c 


30412 


H 


30552 


H 


30780 


B 


3131 


B 


30113 


c 


30413 


H 


30553 


H 


30781 


512 


31321 


B 


30120 


c 


30420 


H 


30560 


H 


30789 


B 


31322 


B 


30121 


c 


30421 


H 


30561 


H 


3079 


B 


31323 


B 


30122 


c 


30422 


H 


30562 


H 


3080 


B 


3133 


B 


3013 


c 


30423 


H 


30563 


H 


3081 


B 


31381 


B 


3014 


c 


30430 


H 


30570 


H 


3082 


B 


31382 


C 


30150 


c 


30431 


H 


30571 


H 


3083 


B 


31383 


B 


30151 


c 


30432 


H 


30572 


H 


3084 


B 


31389 


B 


30159 


c 


30433 


H 


30573 


H 


3089 


B 


3139 


B 


3016 


c 


30440 


H 


30580 


H 


3090 


B 


31400 


B 


3017 


c 


30441 


H 


30581 


H 


3091 


B 


31401 


B 


30181 


c 


30442 


H 


30582 


H 


30921 


B 


3141 


B 


30182 


c 


30443 


H 


30583 


H 


30922 


B 


3142 


B 


30183 


c 


30450 


H 


30590 


H 


30923 


B 


3148 


B 


30184 


c 


30451 


H 


30591 


H 


30924 


B 


3149 


B 


30189 


c 


30452 


H 


30592 


H 


30928 


B 


31500 


B 


3019 


c 


30453 


H 


30593 


H 


30929 


B 


31501 


B 


3020 


c 


30460 


H 


3060 


622 


3093 


B 


31502 


B 


3021 


c 


30461 


H 


3061 


563 


3094 


B 


31509 


B 


3022 


c 


30462 


H 


3062 


576 


30981 


B 


3151 


B 


3023 


c 


30463 


H 


3063 


635 


30982 


B 


3152 


B 


3024 


c 


30470 


H 


3064 


5% 


30983 


B 


31531 


B 


30250 


c 


30471 


H 


30650 


G 


30989 


B 


31539 


B 


30251 


c 


30472 


H 


30651 


681 


3099 


B 


3154 


B 


30252 


c 


30473 


H 


30652 


681 


3100 


296 


3155 


B 


30253 


c 


30480 


H 


30653 


G 


3101 


296 


3158 


B 


3026 


c 


30481 


H 


30659 


G 


3102 


512 


3159 


B 


30270 


B 


30482 


H 


3066 


653 


3108 


296 


316 


C 


30271 


B 


30483 


H 


3067 


B 


3109 


296 


317 


296 


30272 


B 


30490 


H 


3068 


B 


311 


B 


3180 


296 


30273 


B 


30491 


H 


3069 


B 


31200 


C 


3181 


296 


30274 


B 


30492 


H 


3070 


B 


31201 


C 


3182 


296 


30275 


B 


30493 


H 


3071 


C 


31202 


C 


319 


296 


30276 


B 


30500 


H 


30720 


515 


31203 


C 


3200 


516 


30279 


B 


30501 


H 


30721 


515 


31210 


C 


3201 


516 



The Development of a Physician Prospective Payment System for Ambulatory Care 



205 



APPENDIX F 


















DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


3202 


516 


33382 


515 


3429 


515 


34620 


512 


3552 


515 


3203 


516 


33383 


515 


34290 


511 


34621 


512 


3553 


515 


3207 


516 


33384 


515 


34291 


511 


34680 


512 


3554 


515 


32081 


516 


33389 


515 


34292 


511 


34681 


512 


3555 


515 


320SZ 


516 


33390 


515 


3430 


516 


34690 


512 


3556 


515 


32089 


516 


33391 


516 


3431 


516 


34691 


512 


3557 


515 


3209 


516 


33392 


515 


3432 


516 


347 


515 


35571 


515 


3210 


516 


33393 


515 


3433 


516 


3480 


516 


35579 


515 


3211 


516 


33399 


515 


3434 


516 


3481 


516 


3558 


515 


3212 


516 


3340 


516 


3438 


516 


3482 


516 


3559 


515 


3213 


516 


3341 


516 


3439 


516 


3483 


516 


3560 


515 


3214 


516 . 


3342 


516 


3440 


516 


3484 


516 


3561 


515 


3218 


516 ■ 


3343 


515 


34400 


516 


3485 


516 


3562 


515 


3220 


516 


3344 


515 


34401 


516 


3488 


515 


3563 


516 


3221 


516 


3348 


516 


34402 


316 


3489 


515 


3564 


515 


3222 


516 


3349 


516 


34403 


516 


3490 


515 


3568 


515 


3229 


516 


3350 


516 


34404 


516 


3491 


515 


3569 


515 


3230 


516 


33510 


516 


34409 


316 


3492 


515 


3570 


516 


3231 


516 


33511 


516 


3441 


516 


34981 


515 


3571 


516 


3232 


516 


33519 


516 


3442 


513 


34982 


516 


3572 


515 


3234 


516 


33520 


516 


3443 


515 


34989 


515 


3573 


515 


3235 


516 


33521 


516 


34430 


515 


3499 


515 


3574 


515 


3236 


516 


33522 


516 


34431 


515 


3501 


515 


3575 


515 


3237 


516 


33523 


516 


34432 


515 


3502 


515 


3576 


515 


3238 


516 


33524 


516 


3444 


515 


3508 


515 


3577 


515 


3239 


516 


33529 


516 


34440 


515 


3509 


515 


3578 


515 


3240 


516 


3358 


516 


34441 


515 


3510 


515 


3579 


515 


3241 


516 


3359 


516 


34442 


515 


3511 


515 


3580 


516 


3249 


516 


3360 


516 


3445 


515 


3518 


515 


3581 


516 


325 


516 


3361 


516 


34460 


515 


3319 


515 


3582 


516 


326 


516 


3362 


516 


34461 


G 


3520 


515 


3588 


516 


3300 


516 


3363 


516 


3448 


516 


3521 


515 


3589 


516 


3301 


516 


3368 


516 


34481 


611 


3522 


513 


3590 


516 


3302 


516 


3369 


515 


34489 


515 


3523 


515 


3591 


516 


3303 


516 


3370 


515 


3449 


515 


3524 


515 


3592 


515 


3308 


516 


3371 


515 


34500 


513 


3525 


515 


3593 


516 


3309 


516 


33720 


516 


34501 


513 


3526 


315 


3594 


515 


3310 


296 


33721 


516 


34510 


513 


3529 


516 


3595 


515 


3311 


296 


33722 


515 


34511 


513 


3530 


515 


3596 


515 


3312 


296 


33729 


515 


3452 


611 


3531 


515 


3598 


515 


3313 


516 


3379 


515 


3153 


611 


3532 


513 


3599 


515 


3314 


516 


340 


516 


34540 


513 


3533 


515 


36000 


534 


3317 


516 


3410 


516 


34541 


513 


3534 


515 


36001 


534 


33181 


516 


3411 


516 


34550 


513 


3535 


515 


36002 


534 


33189 


516 


3418 


516 


34551 


513 


3536 


515 


36003 


534 


3319 


516 


3419 


516 


34560 


513 


3538 


515 


36004 


534 


3320 


515 


3420 


515 


34561 


513 


3539 


515 


36011 


534 


3321 


516 


34200 


511 


34570 


513 


3540 


515 


36012 


534 


3330 


516 


34201 


511 


34571 


513 


3541 


515 


36013 


534 


3331 


515 


34202 


511 


34580 


513 


3542 


513 


36014 


534 


3332 


515 


3421 


515 


34581 


513 


3543 


315 


36019 


534 


3333 


515 


34210 


511 


34590 


513 


3544 


515 


36020 


534 


3334 


516 


34211 


511 


34591 


513 


3545 


513 


36021 


534 


3335 


515 


34212 


511 


34600 


512 


3548 


315 


36023 


534 


3336 


516 


34280 


511 


34601 


512 


3549 


515 


36024 


534 


3337 


516 


34281 


511 


34610 


512 


3550 


515 


36029 


534 


33381 


534 


34282 


511 


34611 


512 


3551 


315 


36030 


534 


206 


















Final Report 



'^^;'i 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


36031 


534 


36217 


534 


36313 


534 


36462 


534 


36613 


531 


36032 


534 


36218 


534 


36314 


534 


36463 


534 


36614 


531 


36033 


534 


36221 


534 


36315 


534 


36464 


534 


36615 


531 


36034 


534 


36229 


534 


36320 


534 


36470 


534 


36616 


531 


36040 


534 


36230 


534 


36321 


534 


36471 


534 


36617 


531 


36041 


534 


36231 


534 


36322 


534 


36472 


534 


36618 


531 


36042 


534 


36232 


534 


36330 


534 


36473 


534 


36619 


531 


36043 


534 


36233 


534 


3633! 


534 


36474 


534 


36620 


531 


36044 


534 


36234 


534 


36332 


534 


36475 


534 


36621 


531 


36050 


534 


36235 


534 


36333 


534 


36476 


534 


36622 


531 


36051 


534 


36236 


534 


36334 


534 


36477 


534 


36623 


531 


36052 


534 . 


36237 


534 


36335 


534 


3648 


534 


36630 


531 


36053 


534 . ' 


36240 


534 


36340 


534 


3649 


534 


36631 


534 


36054 


534 


36241 


534 


36341 


534 


36500 


534 


36632 


531 


36055 


534 


36242 


534 


36342 


534 


36501 


534 


36633 


531 


36059 


534 


36243 


534 


36343 


534 


36502 


534 


36634 


531 


36060 


534 


36250 


534 


36350 


534 


36503 


534 


36641 


531 


36061 


534 


36251 


534 


36351 


534 


36504 


534 


36642 


531 


36062 


534 


36252 


534 


36352 


534 


36510 


534 


36643 


531 


36063 


534 


36253 


534 


36353 


534 


36511 


534 


36644 


531 


36064 


534 


36254 


534 


36354 


534 


36512 


534 


36645 


531 


36065 


534 


36255 


534 


36355 


534 


36513 


534 


36646 


531 


36069 


534 


36256 


534 


36356 


534 


36514 


534 


36650 


531 


36081 


534 


36257 


534 


36357 


534 


36515 


534 


36651 


531 


36089 


534 


36260 


534 


36361 


534 


36520 


534 


36652 


531 


3609 


534 


36261 


534 


36362 


534 


36521 


534 • 


36653 


531 


36100 


534 


36262 


534 


36363 


534 


36522 


534 


3668 


531 


36101 


534 


36263 


534 


36370 


534 


36523 


534 


3669 


531 


36102 


534 


36264 


534 


36371 


534 


36524 


534 


3670 


532 


36103 


534 


36265 


534 


36372 


534 


36531 


534 


3671 


532 


36104 


534 


36266 


534 


3638 


534 


36532 


534 


36720 


532 


36105 


534 


36270 


534 


3639 


534 


36541 


534 


36721 


532 


36106 


534 


36271 


534 


36400 


534 


36542 


534 


36722 


532 


36107 


534 


36272 


534 


36401 


534 


36543 


534 


36731 


532 


36110 


534 


36273 


534 


36402 


534 


36544 


534 


36732 


532 


36111 


534 


36274 


534 


36403 


534 


36551 


534 


3674 


532 


36112 


534 


36275 


534 


36404 


534 


36552 


534 


36751 


532 


36113 


534 


36276 


534 


36405 


534 


36559 


534 


36752 


532 


36114 


534 


36277 


534 


36410 


534 


36560 


534 


36753 


532 


36119 


534 


36281 


534 


36411 


534 


36561 


534 


36781 


532 


3612 


534 


36282 


534 


36421 


534 


36562 


534 


36789 


532 


36130 


534 


36283 


534 


36422 


534 


36563 


534 


3679 


532 


36131 


534 


36284 


534 


36423 


534 


36564 


534 


36800 


532 


36132 


534 


36285 


534 


36424 


534 


36565 


534 


36801 


532 


36133 


534 


36289 


534 


3643 


534 


36581 


534 


36802 


532 


36181 


534 


3629 


534 


36441 


534 


36582 


534 


36803 


532 


36189 


534 


36300 


534 


36442 


534 


36589 


534 


36810 


534 


3619 


534 


36301 


534 


36451 


534 


3659 


534 


36811 


534 


36201 


534 


36303 


534 


36452 


534 


36600 


531 


36812 


534 


36202 


534 


36304 


534 


36453 


534 


36601 


531 


36813 


534 


36210 


534 


36305 


534 


36454 


534 


36602 


531 


36814 


534 


36211 


534 


36306 


534 


36455 


534 


36603 


531 


36815 


534 


36212 


534 


36307 


534 


36456 


534 


36604 


531 


36816 


534 


36213 


534 


36308 


534 


36457 


534 


36609 


531 


3682 


534 


36214 


534 


36310 


534 


36459 


534 


36610 


531 


36830 


534 


36215 


534 


36311 


534 


36460 


534 


36611 


531 


36831 


534 


36216 


534 


36312 


534 


36461 


534 


36612 


531 


36832 


534 



The Development of a Physician Prospective Payment System for Ambulatory Care 



207 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


36833 


534 


36968 


534 


37120 


534 


37240 


534 


37432 


534 


36834 


534 


36969 


534 


37121 


534 


37241 


534 


37433 


534 


36840 


534 


36970 


534 


37122 


534 


37242 


534 


37434 


534 


36841 


534 


36971 


534 


37123 


534 


37243 


534 


37441 


534 


36842 


534 


36972 


534 


37124 


534 


37244 


534 


37443 


534 


36843 


534 


36973 


534 


37130 


534 


37245 


534 


37444 


534 


36844 


534 


36974 


534 


37131 


534 


37250 


534 


37445 


534 


36845 


534 


36975 


534 


37132 


534 


37251 


534 


37446 


534 


36846 


534 


36976 


534 


37133 


534 


37252 


534 


37450 


534 


36847 


534 


3698 


534 


37140 


534 


37253 


534 


37451 


635 


36851 


534 


3699 


534 


37141 


534 


37254 


533 


37452 


534 


36852 


534 


37000 


534 


37142 


534 


37255 


533 


37453 


534 


36853 


534 ■ 


37001 


534 


37143 


534 


37256 


533 


37454 


534 


36854 


534 


37002 


534 


37144 


534 


37261 


534 


37455 


534 


36855 


534 


37003 


534 


37145 


534 


37262 


534 


37456 


534 


36859 


534 


37004 


534 


37146 


534 


37263 


534 


37481 


534 


36860 


534 


37005 


534 


37148 


534 


37264 


534 


37482 


534 


36861 


534 


37006 


534 


37149 


534 


37271 


534 


37483 


534 


36862 


534 


37007 


534 


37150 


534 


37272 


534 


37484 


534 


36863 


534 


37020 


534 


37151 


534 


37273 


534 


37485 


534 


36869 


534 


37021 


534 


37152 


534 


37274 


534 


37486 


534 


3688 


534 


37022 


534 


37153 


534 


37275 


534 


37487 


534 


3689 


534 


37023 


534 


37154 


534 


3728 


534 


37489 


534 


36900 


534 


37024 


534 


37155 


534 


3729 


534 


3749 


534 


36901 


534 


37031 


534 


37156 


534 


37300 


533 


37500 


533 


36902 


534 


37032 


534 


37157 


534 


37301 


533 


37501 


533 


36903 


534 


37033 


534 


37158 


534 


37302 


533 


37502 


533 


36904 


534 


37034 


534 


37160 


534 


37311 


533 


37503 


534 


36905 


534 


37035 


534 


37161 


534 


37312 


533 


37511 


534 


36906 


534 


37040 


534 


37162 


534 


37313 


533 


37512 


534 


36907 


534 


37044 


534 


37170 


534 


3732 


533 


37513 


534 


36908 


534 


37049 


534 


37171 


534 


37331 


534 


37514 


534 


36910 


534 


37050 


534 


37172 


534 


37332 


534 


37515 


534 


36911 


534 


37052 


534 


37173 


534 


37333 


534 


37516 


534 


36912 


534 


37054 


534 


37181 


534 


37334 


534 


37520 


534 


36913 


534 


37055 


534 


37182 


534 


3734 


534 


37521 


534 


36914 


534 


37059 


534 


37189 


534 


3735 


533 


37522 


534 


36915 


534 


37060 


534 


3719 


534 


3736 


534 


37530 


533 


36916 


534 


37061 


534 


37200 


533 


3738 


533 


37531 


533 


36917 


534 


37062 


534 


37201 


533 


3739 


533 


37532 


533 


36918 


534 


37063 


534 


37202 


533 


37400 


534 


37533 


533 


36920 


534 


37064 


534 


37203 


533 


37401 


534 


37541 


533 


36921 


534 


3708 


534 


37204 


533 


37402 


534 


37542 


533 


36922 


534 


3709 


534 


37205 


533 


37403 


534 


37543 


534 


36923 


534 


37100 


534 


37210 


533 


37404 


534 


37551 


534 


36924 


534 


37101 


534 


37211 


533 


37405 


534 


37552 


534 


36925 


534 


37102 


534 


37212 


533 


37410 


534 


37553 


534 


3693 


534 


37103 


534 


37213 


533 


37411 


534 


37554 


534 


3694 


534 


37104 


534 


37214 


534 


37412 


534 


37555 


534 


36960 


534 


37105 


534 


37215 


534 


37413 


534 


37556 


534 


36961 


534 


37110 


534 


37220 


533 


37414 


534 


37557 


534 


36962 


534 


37111 


534 


37221 


534 


37420 


534 


37561 


534 


36963 


534 


37112 


534 


37222 


533 


37421 


534 


37569 


534 


36964 


534 


37113 


534 


37230 


533 


37422 


534 


37581 


534 


36965 


534 


37114 


534 


37231 


533 


37423 


534 


37589 


534 


36966 


534 


37115 


534 


37233 


533 


37430 


534 


3759 


534 


36967 


534 


37116 


534 


37239 


533 


37431 


534 


37600 


534 


208 
















1 


Final Report 



<&■'?• 















1 


Ulap of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


37601 


534 


37749 


534 


37862 


534 


37959 


534 


38201 


E 


37602 


534 


37751 


515 


37863 


534 


3798 


534 


38202 


E 


37603 


534 


37752 


515 


37871 


534 


37990 


534 


3821 


544 


37604 


534 


37753 


515 


37872 


534 


37991 


534 


3822 


544 


37610 


534 


37754 


516 


37873 


534 


37992 


534 


3823 


E 


37611 


534 


37761 


516 


37881 


534 


37993 


533 


3824 


E 


37612 


534 


37762 


515 


37882 


534 


37999 


534 


3829 


E 


37613 


534 


37763 


515 


37883 


534 


38000 


544 


38300 


545 


37621 


534 


37771 


516 


37884 


534 


38001 


622 


38301 


545 


37622 


534 


37772 


515 


37885 


534 


38002 


622 


38302 


545 


37630 


534 


37773 


515 


37886 


515 


38010 


544 


3831 


544 


37631 


534 . 


37775 


516 


37887 


534 


38011 


544 


38320 


544 


37632 


534 . " 


3779 


515 


3789 


534 


38012 


E 


38321 


545 


37633 


534 


37800 


534 


37900 


534 


38013 


E 


38322 


544 


37634 


534 


37801 


534 


37901 


534 


38014 


545 


38330 


E 


37635 


534 


37802 


534 


37902 


534 


38015 


544 


38331 


E 


37636 


534 


37803 


534 


37903 


534 


38016 


544 


38332 


E 


37640 


534 


37804 


534 


37904 


534 


38021 


544 


38333 


544 


37641 


534 


37805 


534 


37905 


534 


38022 


E 


38381 


544 


37642 


534 


37806 


534 


37906 


534 


38023 


544 


38389 


544 


37643 


534 


37807 


534 


37907 


534 


38030 


544 


3839 


544 


37644 


534 


37808 


534 


37909 


534 


38031 


544 


38400 


544 


37645 


534 


37810 


534 


37911 


534 


38032 


544 


38401 


544 


37646 


534 


37811 


534 


37912 


534 


38039 


544 


38409 


E 


37647 


534 


37812 


534 


37913 


534 


3804 


544 


3841 


544 


37650 


534 


37813 


534 


37914 


534 


38050 


544 


38420 


544 


37651 


534 


37814 


534 


37915 


534 


38051 


545 


38421 


544 


37652 


534 


37815 


534 


37916 


534 


38052 


545 


38422 


544 


3766 


534 


37816 


534 


37919 


534 


38053 


545 


38423 


544 


37681 


534 


37817 


534 


37921 


534 


38081 


544 


38424 


545 


37682 


534 


37818 


534 


37922 


534 


38089 


544 


38425 


545 


37689 


534 


37820 


534 


37923 


534 


3809 


544 


38481 


544 


3769 


534 


37821 


534 


37924 


534 


38100 


E 


38482 


544 


37700 


534 


37822 


534 


37925 


534 


38101 


E 


3849 


544 


37701 


534 


37823 


534 


37926 


534 


38102 


E 


38500 


544 


37702 


534 


37824 


534 


37929 


534 


38103 


E 


38501 


544 


37703 


534 


37830 


534 


37931 


534 


38104 


E 


38502 


544 


37704 


516 


37831 


534 


37932 


534 


38105 


E 


38503 


544 


37710 


515 


37832 


534 


37933 


534 


38106 


E 


38509 


544 


37711 


515 


37833 


534 


37934 


534 


38110 


E 


38510 


544 


37712 


515 


37834 


534 


37939 


534 


38119 


E 


38511 


544 


37713 


515 


37835 


534 


37940 


534 


38120 


E 


38512 


544 


37714 


515 


37840 


534 


37941 


534 


38129 


E 


38513 


544 


37715 


515 


37841 


534 


37942 


534 


3813 


E 


38519 


544 


37716 


515 


37842 


534 


37943 


534 


3814 


E 


38521 


544 


37721 


534 


37843 


534 


37945 


534 


38150 


544 


38522 


544 


37722 


516 


37844 


534 


37946 


534 


38151 


544 


38523 


544 


37723 


534 


37845 


534 


37949 


534 


38152 


544 


38524 


544 


37724 


611 


37850 


534 


37950 


534 


38160 


544 


38530 


544 


37730 


534 


37851 


534 


37951 


534 


38161 


544 


38531 


544 


37731 


534 


37852 


534 


37952 


534 


38162 


544 


38532 


544 


37732 


534 


37853 


534 


37953 


534 


38163 


544 


38533 


544 


37733 


534 


37854 


534 


37954 


534 


3817 


544 


38535 


544 


37734 


534 


37855 


534 


37955 


534 


38181 


544 


38582 


544 


37739 


516 


37856 


534 


37956 


534 


38189 


544 


38583 


544 


37741 


534 


37860 


534 


37957 


534 


3819 


544 


38589 


544 


37742 


534 


37861 


534 


37958 


534 


38200 


E 


3859 


544 



The Development of a Physician Prospective Payment System for Ambulatory Care 



209 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


38600 


545 


38872 


544 


40300 


662 


41189 


571 


4255 


576 


38601 


545 


3888 


543 


40301 


662 


412 


575 


4257 


576 


38602 


545 


3889 


543 


40310 


662 


4130 


574 


4258 


576 


38603 


545 


38900 


543 


40311 


662 


4131 


574 


4259 


576 


38604 


544 


38901 


543 


40390 


662 


4139 


574 


4260 


576 


38610 


545 


38902 


543 


40391 


662 


4140 


575 


42610 


575 


38611 


544 


38903 


543 


40400 


570 


41400 


571 


42611 


575 


38612 


545 


38904 


543 


40401 


571 


41401 


571 


42612 


576 


38619 


545 


38908 


543 


40402 


662 


41402 


571 


42613 


576 


3862 


545 


38910 


543 


40403 


571 


41403 


571 


4262 


575 


38630 


545 


38911 


543 


40410 


570 


41410 


576 


4263 


575 


38631 


544 . 


38912 


543 


40411 


571 


41411 


576 


4264 


575 


38632 


545 . ' 


38914 


543 


40412 


662 


41419 


576 


42650 


575 


38633 


545 


38918 


543 


40413 


571 


4148 


571 


42651 


575 


38634 


545 


3892 


543 


40490 


570 


4149 


575 


42652 


575 


38635 


545 


3897 


543 


40491 


571 


4150 


576 


42653 


575 


38640 


545 


3898 


543 


40492 


662 


4151 


564 


42654 


576 


38641 


544 


3899 


543 


40493 


571 


41511 


564 


4266 


575 


38642 


544 


390 


622 


40501 


570 


41519 


564 


4267 


576 


38643 


544 


3910 


576 


40509 


570 


4160 


576 


42681 


576 


38648 


544 


3911 


576 


40511 


570 


4161 


576 


42689 


575 


38650 


544 


3912 


576 


40519 


570 


4168 


575 


4269 


575 


38651 


544 


3918 


576 


40591 


570 


4169 


575 


4270 


576 


38652 


544 


3919 


576 


40599 


570 


4170 


575 


4271 


611 


38653 


544 


3920 


576 


41000 


571 


4171 


575 


4272 


575 


38654 


544 


3929 


576 


41001 


571 


4178 


575 • 


42731 


575 


38655 


545 


393 


576 


41002 


571 


4179 


575 


42732 


576 


38656 


545 


3940 


575 


41010 


571 


4200 


576 


42741 


611 


38658 


544 


3941 


576 


41011 


571 


42090 


576 


42742 


611 


3868 


545 


3942 


576 


41012 


571 


42091 


576 


4275 


611 


3869 


544 


3949 


576 


41020 


571 


42099 


576 


42760 


575 


3870 


543 


3950 


576 


41021 


571 


4210 


576 


42761 


575 


3871 


543 


3951 


576 


41022 


571 


4211 


576 


42769 


576 


3872 


543 


3952 


576 


41030 


571 


4219 


576 


42781 


576 


3878 


543 


3959 


576 


41031 


571 


4220 


576 


42789 


576 


3879 


543 


3960 


576 


41032 


571 


42290 


576 


4279 


575 


38800 


543 


3%1 


576 


41040 


571 


42291 


576 


4280 


571 


38801 


543 


3%2 


576 


41041 


571 


42292 


576 


4281 


571 


38802 


543 


3%3 


576 


41042 


571 


42293 


576 


4289 


571 


38810 


543 


3%8 


576 


41050 


571 


42299 


576 


4290 


575 


38811 


543 


3%9 


576 


41051 


571 


4230 


576 


4291 


575 


38812 


543 


3970 


576 


41052 


571 


4231 


576 


4292 


575 


3882 


543 


3971 


576 


41060 


571 


4232 


576 


4293 


576 


38830 


544 


3979 


576 


41061 


571 


4238 


575 


4294 


576 


38831 


544 


3980 


576 


41062 


571 


4239 


575 


4295 


576 


38832 


544 


39890 


575 


41070 


571 


4240 


575 


4296 


576 


38840 


543 


39891 


575 


41071 


571 


4241 


575 


42971 


575 


38841 


543 


39899 


575 


41072 


571 


4242 


575 


42979 


575 


38842 


543 


4010 


570 


41080 


571 


4243 


575 


42981 


575 


38843 


543 


4011 


569 


41081 


571 


42490 


575 


42982 


575 


38844 


543 


4019 


569 


41082 


571 


42491 


576 


42989 


575 


3885 


545 


40200 


570 


41090 


571 


42499 


576 


4299 


575 


38860 


544 


40201 


570 


41091 


571 


4250 


576 


430 


516 


38861 


515 


40210 


570 


41092 


571 


4251 


576 


431 


511 


38869 


544 


40211 


570 


4110 


571 


4252 


576 


4320 


511 


38870 


544 


40290 


571 


4111 


574 


4253 


576 


4321 


511 


38871 


544 


40291 


570 


41181 


571 


4254 


576 


4329 


511 


210 


















Final Report 



;;:•«-. 

















Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


4330 


511 


4409 


575 


4489 


576 


4610 


E 


47830 


544 


43300 


511 


4410 


611 


4510 


575 


4611 


E 


47831 


544 


43301 


511 


44100 


611 


45111 


576 


4612 


E 


47832 


544 


4331 


511 


44101 


611 


45119 


576 


4613 


E 


47833 


544 


43310 


511 


44102 


611 


4512 


575 


4618 


E 


47834 


544 


43311 


511 


44103 


611 


45181 


576 


4619 


E 


4784 


544 


4332 


511 


4411 


611 


45182 


575 


462 


E 


4785 


544 


43320 


511 


4412 


576 


45183 


575 


463 


E 


4786 


545 


43321 


511 


4413 


611 


45184 


575 


4640 


E 


47870 


544 


4333 


511 


4414 


575 


45189 


575 


46410 


E 


47871 


E 


43330 


511 


4415 


611 


4519 


575 


46411 


E 


47874 


545 


43331 


511 . 


4416 


611 


452 


593 


46420 


E 


47875 


544 


4338 


511 


4417 


575 


4530 


593 


46421 


E 


47879 


544 


43380 


511 


4419 


575 


4531 


575 


46430 


545 


4788 


544 


43381 


511 


4420 


575 


4532 


576 


46431 


611 


4789 


544 


4339 


511 


4421 


665 


4533 


665 


4644 


E 


4800 


562 


43390 


511 


4422 


575 


4538 


575 


4650 


E 


4801 


562 


43391 


511 


4423 


575 


4539 


575 


4658 


E 


4802 


562 


4340 


511 


44281 


575 


4540 


575 


4659 


E 


4808 


562 


43400 


511 


44282 


576 


4541 


575 


4660 


E 


4809 


562 


43401 


511 


44283 


576 


4542 


575 


4661 


E 


481 


562 


4341 


511 


44284 


576 


4549 


575 


470 


544 


4820 


562 


43410 


511 


44289 


575 


4550 


595 


4710 


544 


4821 


562 


43411 


511 


4429 


575 


4551 


595 


4711 


544 


4822 


562 


4349 


511 


4430 


694 


4552 


595 


4718 


544 


48230 


562 


43490 


511 


4431 


576 


4553 


595 


4719 


544 


48231 


562 


43491 


511 


44381 


575 


4554 


595 


4720 


544 


48232 


562 


4350 


511 


44389 


575 


4555 


595 


4721 


E 


48239 


562 


4351 


511 


4439 


575 


4556 


595 


4722 


E 


4824 


562 


4352 


511 


4440 


576 


4557 


595 


4730 


E 


48281 


562 


4353 


511 


4441 


576 


4558 


595 


4731 


E 


48282 


562 


4358 


511 


44421 


576 


4559 


595 


4732 


E 


48283 


562 


4359 


511 


44422 


575 


4560 


597 


4733 


E 


48289 


562 


436 


511 


44481 


576 


4561 


597 


4738 


E 


4829 


562 


4370 


515 


44489 


576 


45620 


597 


4739 


E 


4830 


562 


4371 


511 


4449 


576 


45621 


597 


4740 


E 


4838 


562 


4372 


511 


4460 


694 


4563 


575 


47410 


E 


4841 


562 


4373 


516 


4461 


694 


4564 


672 


47411 


E 


4843 


562 


4374 


516 


44620 


693 


4565 


672 


47412 


E 


4845 


564 


4375 


516 


44621 


693 


4566 


681 


4742 


E 


4846 


564 


4376 


516 


44629 


693 


4568 


575 


4748 


E 


4847 


564 


4377 


705 


4463 


694 


4570 


635 


4749 


E 


4848 


562 


4378 


515 


4464 


694 


4571 


633 


475 


E 


485 


562 


4379 


515 


4465 


693 


4572 


633 


4760 


E 


486 


562 


438 


516 


4466 


694 


4578 


693 


4761 


E 


4870 


562 


4400 


576 


4467 


694 


4579 


693 


4770 


544 


4871 


E 


4401 


665 


4470 


575 


4580 


575 


4778 


544 


4878 


E 


44020 


575 


4471 


576 


4581 


575 


4779 


544 


490 


F 


44021 


575 


4472 


611 


4582 


653 


4780 


544 


4910 


F 


44022 


575 


4473 


665 


4589 


575 


4781 


544 


4911 


F 


44023 


575 


4474 


597 


4590 


705 


47820 


544 


49120 


F 


44024 


576 


4475 


576 


4591 


575 


47821 


E 


49121 


F 


44029 


575 


4476 


622 


4592 


575 


47822 


E 


4918 


F 


44030 


575 


4478 


576 


45981 


575 


47824 


E 


4919 


F 


44031 


575 


4479 


576 


45989 


575 


47825 


E 


4920 


F 


44032 


575 


4480 


576 


4599 


575 


47826 


E 


4928 


F 


4408 


575 


4481 


635 


460 


E 


47829 


E 


49300 


F 



The Development of a Physician Prospective Payment System for Ambulatory Care 



211 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


49301 


611 


5171 


564 


5239 


541 


5282 


544 


53220 


611 


49310 


F 


5172 


564 


52400 


545 


5283 


E 


53221 


611 


49311 


611 


5178 


564 


52401 


545 


5284 


544 


53230 


592 


49320 


F 


5180 


564 


52402 


545 


5285 


544 


53231 


592 


49321 


611 


5181 


F 


52403 


545 


5286 


544 


53240 


592 


49390 


F 


5182 


F 


52404 


545 


5287 


544 


53241 


592 


49391 


611 


5183 


564 


52405 


545 


5288 


544 


53250 


611 


494 


F 


5184 


564 


52406 


545 


5289 


544 


53251 


611 


4950 


564 


5185 


564 


52409 


545 


5290 


544 


53260 


611 


4951 


564 


51881 


564 


52410 


545 


5291 


544 


53261 


611 


4952 


564 


51882 


564 


52411 


545 


5292 


544 


53270 


592 


4953 


564 . 


51889 


563 


52412 


545 


5293 


544 


53271 


592 


4954 


564/ 


5190 


564 


52419 


545 


5294 


544 


53290 


592 


4955 


564 


5191 


564 


5242 


541 


5295 


544 


53291 


592 


4956 


564 


5192 


564 


5243 


541 


5296 


544 


53300 


592 


4957 


564 


5193 


563 


5244 


541 


5298 


544 


53301 


592 


4958 


564 


5194 


563 


5245 


541 


5299 


544 


53310 


611 


4959 


564 


5198 


705 


52460 


622 


5300 


596 


53311 


611 


496 


F 


5199 


705 


52461 


622 


5301 


592 


53320 


611 


500 


564 


5200 


541 


52462 


622 


53010 


592 


53321 


611 


501 


564 


5201 


541 


52463 


622 


53011 


592 


53330 


592 


502 


564 


5202 


541 


52469 


622 


53019 


592 


53331 


592 


503 


564 


5203 


541 


52470 


541 


5302 


596 


53340 


592 


504 


564 


5204 


541 


52471 


541 


5303 


596 


53341 


592 


505 


564 


5205 


541 


52472 


541 


5304 


597 


53350 


611 


5060 


564 


5206 


541 


52473 


541 


5305 


596 


53351 


611 


5061 


564 


5207 


541 


52474 


541 


5306 


596 


53360 


611 


5062 


564 


5208 


541 


52479 


541 


5307 


597 


53361 


611 


5063 


564 


5209 


541 


5248 


541 


5308 


596 


53370 


592 


5064 


564 


5210 


541 


5249 


541 


53081 


592 


53371 


592 


5069 


564 


5211 


541 


5250 


541 


53082 


597 


53390 


592 


5070 


564 


5212 


541 


5251 


541 


53083 


597 


53391 


592 


5071 


564 


5213 


541 


5252 


541 


53084 


597 


53400 


592 


5078 


564 


5214 


541 


5253 


541 


53089 


596 


53401 


592 


5080 


564 


3215 


541 


5258 


541 


5309 


592 


53410 


611 


5081 


564 


5216 


541 


5259 


541 


53100 


592 


53411 


611 


5088 


563 


5217 


541 


5260 


541 


53101 


593 


53420 


611 


5089 


563 


5218 


541 


5261 


544 


53110 


611 


53421 


611 


5100 


564 


5219 


541 


5262 


544 


53111 


611 


53430 


592 


5109 


564 


5220 


541 


5263 


544 


53120 


611 


53431 


592 


5110 


563 


5221 


541 


5264 


544 


53121 


611 


53440 


592 


5111 


564 


527.?. 


541 


5265 


544 


53130 


592 


53441 


592 


5118 


564 


5223 


541 


52681 


544 


53131 


592 


53450 


611 


5119 


564 


5224 


541 


52689 


544 


53140 


592 


53451 


611 


5120 


564 


5225 


541 


5269 


544 


53141 


593 


53460 


611 


5121 


611 


5226 


541 


5270 


544 


53150 


611 


53461 


611 


5128 


564 


5227 


541 


5271 


544 


53151 


611 


53470 


592 


5130 


564 


5228 


541 


5272 


544 


53160 


611 


53471 


592 


5131 


564 


5229 


541 


5273 


E 


53161 


611 


53490 


592 


514 


564 


5230 


541 


5274 


544 


53170 


592 


53491 


592 


515 


563 


5231 


541 


5275 


544 


53171 


592 


53500 


592 


5160 


564 


5232 


541 


5276 


544 


53190 


592 


53501 


592 


5161 


564 


5233 


541 


5277 


544 


53191 


592 


53510 


592 


5162 


564 


5234 


541 


5278 


544 


53200 


592 


53511 


592 


5163 


564 


5235 


541 


5279 


544 


53201 


592 


53520 


592 


5168 


564 


5236 


541 


5280 


544 


53210 


611 


53521 


592 


5169 


564 


5238 


541 


5281 


544 


53211 


611 


53530 


592 


212 


















Final Report 



>i^ 

















Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


53531 


592 


55202 


596 


5640 


596 


5723 


593 


58089 


665 


53540 


592 


55203 


596 


5641 


596 


5724 


593 


5809 


665 


53541 


592 


5521 


596 


5642 


597 


5728 


593 


5810 


665 


53550 


592 


55220 


596 


5643 


597 


5730 


593 


5811 


665 


53551 


592 


55221 


596 


5644 


597 


5731 


593 


5812 


665 


53560 


592 


55229 


596 


5645 


596 


5732 


593 


5813 


665 


53561 


592 


5523 


596 


5646 


595 


5733 


593 


58181 


665 


5360 


596 


5528 


596 


5647 


597 


5734 


593 


58189 


665 


5361 


597 


5529 


596 


5648 


596 


5738 


593 


5819 


665 


5362 


K 


55300 


594 


5649 


596 


5739 


593 


5820 


665 


5363 


597 


55301 


594 


5650 


595 


57400 


593 


5821 


665 


5368 


596 . 


55302 


594 


5651 


595 


57401 


593 


5822 


665 


5369 


596 . ■ 


55303 


594 


566 


595 


57410 


593 


5824 


665 


5370 


597 


5531 


594 


5670 


597 


57411 


593 


58281 


665 


5371 


597 


55320 


594 


5671 


597 


57420 


593 


58289 


665 


5372 


597 


55321 


594 


5672 


597 


57421 


593 


5829 


665 


5373 


597 


55329 


594 


5678 


597 


57430 


593 


5830 


665 


5374 


597 


5533 


594 


5679 


597 


57431 


593 


5831 


665 


5375 


597 


5538 


594 


5680 


596 


57440 


593 


5832 


665 


5376 


597 


5539 


594 


56881 


611 


57441 


593 


5834 


665 


53781 


596 


5550 


597 


56882 


596 


57450 


593 


5836 


665 


53782 


592 


5551 


597 


56889 


596 


57451 


593 


5837 


665 


53783 


592 


5552 


597 


5689 


596 


5750 


593 


58381 


665 


53789 


596 


5559 


596 


5690 


595 


5751 


593 


58389 


665 


5379 


596 


556 


596 


5691 


595 


5752 


593 


5839 


665 


5400 


597 


5560 


596 


5692 


595 


5753 


593 


5845 


G 


5401 


597 


5561 


596 


5693 


596 


5754 


593 


5846 


6£2 


5409 


597 


5562 


596 


56941 


595 


5755 


593 


5847 


662 


541 


597 


5563 


596 


56942 


595 


5756 


593 


5848 


662 


542 


597 


5564 


596 


56949 


595 


5758 


593 


5849 


662 


5430 


596 


5565 


596 


5695 


597 


5759 


593 


585 


662 


5439 


596 


5566 


596 


5696 


596 


5760 


593 


586 


662 


55000 


594 


5568 


596 


56%0 


597 


5761 


593 


587 


665 


55001 


594 


5569 


596 


56% 1 


597 


5762 


593 


5880 


665 


55002 


594 


5570 


597 


56%9 


597 


5763 


593 


5881 


665 


55003 


594 


5571 


596 


56981 


597 


5764 


593 


5888 


G 


55010 


594 


5579 


596 


56982 


597 


5765 


593 


5889 


G 


55011 


594 


5581 


K 


56983 


597 


5768 


593 


5890 


G 


55012 


594 


5582 


K 


56984 


597 


5769 


593 


5891 


G 


55013 


594 


5589 


K 


56985 


597 


5770 


593 


5899 


G 


55090 


594 


5600 


597 


56989 


596 


5771 


593 


59000 


665 


55091 


594 


5601 


597 


5699 


5% 


5772 


593 


59001 


665 


55092 


594 


5602 


597 


570 


593 


5778 


593 


59010 


665 


55093 


594 


56030 


596 


5710 


593 


5779 


593 


59011 


G 


55100 


594 


56031 


597 


5711 


593 


5780 


597 


5902 


665 


55101 


594 


56039 


596 


5712 


593 


5781 


596 


5903 


665 


55102 


594 


56081 


597 


5713 


593 


5789 


592 


59080 


665 


55103 


594 


56089 


597 


57140 


593 


5790 


597 


59081 


G 


5511 


594 


5609 


597 


57141 


593 


5791 


597 


5909 


G 


55120 


594 


56200 


596 


57149 


593 


5792 


597 


591 


665 


55121 


594 


56201 


596 


5715 


593 


5793 


597 


5920 


665 


55129 


594 


56202 


596 


5716 


597 


5794 


597 


5921 


665 


5513 


611 


56203 


597 


5718 


593 


5798 


596 


5929 


665 


5518 


611 


56210 


596 


5719 


593 


5799 


596 


5930 


G 


5519 


611 


56211 


596 


5720 


593 


5800 


665 


5931 


G 


55200 


596 


56212 


596 


5721 


593 


5804 


665 


5932 


G 


55201 


596 


56213 


597 


5722 


611 


58081 


665 


5933 


G 



The Development of a Physician Prospective Payment System for Ambulatory Care 



213 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


5934 


G 


5996 


665 


6101 


634 


6187 


681 


6250 


681 


5935 


665 


5997 


665 


6102 


634 


6188 


681 


6251 


681 


5936 


G 


59981 


G 


6103 


634 


6189 


681 


6252 


681 


5937 


G 


59982 


G 


6104 


634 


6190 


681 


6253 


681 


59370 


665 


59983 


G 


6108 


634 


6191 


597 


6254 


681 


59371 


665 


59984 


G 


6109 


634 


6192 


681 


6255 


681 


59372 


665 


59989 


G 


6110 


634 


6198 


681 


6256 


681 


59373 


665 


5999 


G 


6111 


634 


6199 


681 


6258 


681 


59381 


G 


600 


G 


6112 


634 


6200 


681 


6259 


681 


59382 


665 


6010 


672 


6113 


634 


6201 


681 


6260 


681 


59389 


G 


6011 


672 


6114 


634 


6202 


681 


6261 


681 


5939 


G 


6012 


672 


6115 


634 


6203 


681 


6262 


681 


5940 


665 .■ 


6013 


672 


6116 


634 


6204 


681 


6263 


681 


5941 


665 


6014 


672 


61171 


634 


6205 


681 


6264 


681 


5942 


665 


6018 


672 


61172 


634 


6206 


681 


6265 


681 


5948 


665 


6019 


672 


61179 


634 


6207 


681 


6266 


681 


5949 


665 


6020 


672 


6118 


634 


6208 


681 


6267 


681 


5950 


661 


6021 


672 


6119 


634 


6209 


681 


6268 


681 


5951 


661 


6022 


672 


6140 


A 


6210 


681 


6269 


681 


5952 


661 


6028 


672 


6141 


A 


6211 


681 


6270 


681 


5953 


661 


6029 


672 


6142 


A 


6212 


681 


6271 


681 


5954 


661 


6030 


672 


6143 


681 


6213 


681 


6272 


681 


59581 


661 


6031 


672 


6144 


681 


6214 


681 


6273 


681 


59582 


665 


6038 


672 


614S 


681 


6215 


681 


6274 


681 


59589 


661 


6039 


672 


6146 


681 


6216 


681 


6278 


681 


5959 


661 


6040 


672 


6147 


681 


6217 


681 


6279 


681 


5960 


665 


60490 


672 


6148 


A 


6218 


681 


6280 


681 


5961 


G 


60491 


672 


6149 


A 


6219 


681 


6281 


681 


5%2 


G 


60499 


672 


6150 


681 


6220 


681 


6282 


681 


5963 


G 


605 


672 


6151 


681 


6221 


681 


6283 


681 


5964 


G 


6060 


672 


6159 


681 


6222 


681 


6284 


681 


59651 


G 


6061 


672 


6160 


A 


6223 


681 


6288 


681 


59652 


G 


6068 


672 


61610 


A 


6224 


681 


6289 


681 


59653 


665 


6069 


672 


61611 


A 


6225 


681 


6290 


681 


59654 


665 


6070 


672 


6162 


681 


6226 


681 


6291 


681 


59655 


G 


6071 


672 


6163 


681 


6227 


681 


6298 


681 


59659 


G 


6072 


672 


6164 


681 


6228 


681 


6299 


681 


5966 


665 


6073 


672 


61650 


681 


6229 


681 


630 


494 


5967 





60781 


672 


61651 


681 


6230 


681 


631 


494 


5968 


G 


60782 


672 


6168 


681 


6231 


681 


632 


492 


5969 


G 


60783 


672 


6169 


681 


6232 


681 


6330 


492 


5970 


G 


60784 


672 


6170 


681 


6233 


681 


6331 


494 


59780 


661 


60789 


672 


6171 


681 


6234 


681 


6332 


494 


59781 


661 


6079 


672 


6172 


681 


6235 


681 


6338 


494 


59789 


661 


6080 


A 


6173 


681 


6236 


681 


6339 


494 


59800 


G 


6081 


672 


6174 


681 


6237 


681 


63400 


494 


59801 


G 


6082 


672 


6175 


597 


6238 


681 


63401 


494 


5981 


G 


6083 


672 


6176 


635 


6239 


681 


63402 


494 


5982 


G 


6084 


672 


6178 


681 


6240 


681 


63410 


494 


5988 


G 


60881 


672 


6179 


681 


6241 


681 


63411 


494 


5989 


G 


60883 


672 


6180 


681 


6242 


681 


63412 


494 


5990 


661 


60884 


672 


6181 


681 


6243 


681 


63420 


494 


5991 


665 


60885 


672 


6182 


681 


6244 


681 


63421 


494 


5992 


G 


60886 


672 


6183 


681 


6245 


681 


63422 


494 


5993 


G 


60889 


672 


6184 


681 


6246 


681 


63430 


494 


5994 


G 


6089 


672 


6185 


681 


6248 


681 


63431 


494 


5995 


G 


6100 


634 


6186 


681 


6249 


681 


63432 


494 


214 


















Final Report 



•-ff 



o 



• 



• 















1 


Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


63440 


494 


63630 


494 


6386 


492 


64232 


998 


64612 


998 


63441 


494 


63631 


494 


6387 


492 


64233 


492 


64613 


491 


63442 


494 


63632 


494 


6388 


492 


64234 


493 


64614 


493 


63450 


494 


63640 


494 


6389 


492 


64240 


493 


64620 


494 


63451 


494 


63641 


494 


6390 


494 


64241 


998 


64621 


998 


63452 


494 


63642 


494 


6391 


494 


64242 


998 


64622 


998 


63460 


494 


63650 


494 


6392 


494 


64243 


492 


64623 


492 


63461 


494 


63651 


494 


6393 


494 


64244 


493 


64624 


494 


63462 


494 


63652 


494 


6394 


494 


64250 


494 


64630 


494 


63470 


494 


63660 


494 


6395 


494 


64251 


998 


64631 


998 


63471 


494 


63661 


494 


6396 


494 


64252 


998 


64633 


492 


63472 


494 . 


63662 


494 


6398 


494 


64253 


492 


64640 


494 


63480 


494 .' 


63670 


494 


6399 


494 


64254 


494 


64641 


998 


63481 


494 


63671 


494 


64000 


492 


64260 


494 


64642 


998 


63482 


494 


63672 


494 


64001 


998 


64261 


998 


64643 


492 


63490 


494 


63680 


494 


64003 


492 


64262 


998 


64644 


494 


63491 


494 


63681 


494 


64080 


492 


64263 


492 


64650 


494 


63492 


494 


63682 


494 


64081 


998 


64264 


494 


64651 


998 


63500 


494 


63690 


494 


64083 


492 


64270 


494 


64652 


998 


63501 


494 


63691 


494 


64090 


492 


64271 


998 


64653 


492 


63502 


494 


63692 


494 


64091 


998 


64272 


998 


64654 


494 


63510 


494 


63700 


494 


64093 


492 


64273 


492 


64660 


494 


63511 


494 


63701 


494 


64100 


492 


64274 


494 


64661 


998 


63512 


494 


63702 


494 


64101 


998 


64290 


494 


64662 


998 


63520 


494 


63710 


494 


64103 


492 


64291 


998 


64663 


492 


63521 


494 


63711 


494 


64110 


492 


64292 


998 


64664 


494 


63522 


494 


63712 


494 


64111 


998 


64293 


492 


64670 


494 


63530 


494 


63720 


494 


64113 


492 


64294 


494 


64671 


998 


63531 


494 


63721 


494 


64120 


492 


64300 


493 


64673 


492 


63532 


494 


63722 


494 


64121 


494 


64301 


998 


64680 


493 


63540 


494 


63730 


494 


64123 


492 


64303 


491 


64681 


998 


63541 


494 


63731 


494 


64130 


494 


64310 


494 


64682 


998 


63542 


494 


63732 


494 


64131 


494 


64311 


998 


64683 


492 


63550 


494 


63740 


494 


64133 


492 


64313 


492 


64684 


493 


63551 


494 


63741 


494 


64180 


494 


64320 


491 


64690 


494 


63552 


494 


63742 


494 


64181 


998 


64321 


998 


64691 


998 


63560 


494 


63750 


494 


64183 


492 


64323 


491 


64693 


492 


63561 


494 


63751 


494 


64190 


494 


64380 


491 


64700 


494 


63562 


494 


63752 


494 


64191 


998 


64381 


998 


64701 


998 


63570 


494 


63760 


494 


64193 


492 


64383 


491 


64702 


998 


63571 


494 


63761 


494 


64200 


494 


64390 


491 


64703 


492 


63572 


494 


63762 


494 


64201 


998 


64391 


998 


64704 


494 


63580 


494 


63770 


494 


64202 


998 


64393 


491 


64710 


494 


63581 


494 


63771 


494 


64203 


492 


64400 


492 


64711 


998 


63582 


494 


63772 


494 


64204 


494 


64403 


492 


64712 


998 


63590 


494 


63780 


494 


64210 


494 


64410 


492 


64713 


492 


63591 


494 


63781 


494 


64211 


998 


64413 


492 


64714 


494 


63592 


494 


63782 


494 


64212 


998 


64420 


492 


64720 


494 


63600 


494 


63790 


494 


64213 


492 


64421 


998 


64721 


998 


63601 


494 


63791 


494 


64214 


494 


64500 


492 


64722 


998 


63602 


494 


63792 


494 


64220 


494 


64501 


998 


64723 


492 


63610 


494 


6380 


492 


64221 


998 


64503 


492 


64724 


494 


63611 


494 


6381 


492 


64222 


998 


64600 


494 


64730 


494 


63612 


494 


6382 


492 


64223 


492 


64601 


998 


64731 


998 


63620 


494 


6383 


492 


64224 


494 


64603 


492 


64732 


998 


63621 


494 


6384 


492 


64230 


493 


64610 


493 


64733 


492 


63622 


494 


6385 


492 


64231 


998 


64611 


998 


64734 


494 



The Development of a Physician Prospective Payment System for Ambulatory Care 



215 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


64740 


494 


64862 


998 


65233 


491 


65413 


492 


65553 


492 


64741 


998 


64863 


492 


65240 


493 


65414 


494 


65560 


494 


64742 


998 


64864 


494 


65241 


998 


65420 


493 


65561 


998 


64743 


492 


64870 


494 


65243 


491 


65421 


998 


65563 


492 


64744 


494 


64871 


998 


65250 


493 


65423 


491 


65580 


494 


64750 


494 


64872 


998 


65251 


998 


65430 


493 


65581 


998 


64751 


998 


64873 


492 


65253 


491 


65431 


998 


65583 


492 


64752 


998 


64874 


494 


65260 


493 


65432 


998 


65590 


494 


64753 


492 


64880 


494 


65261 


998 


65433 


491 


65591 


998 


64754 


494 


64881 


998 


65263 


492 


65434 


493 


65593 


492 


64760 


494 


64882 


998 


65270 


493 


65440 


494 


65600 


494 


64761 


998 . 


64883 


492 


65271 


998 


65441 


998 


65601 


998 


64762 


998 . ■ 


64884 


494 


65273 


492 


65442 


998 


65603 


492 


64763 


492 


64890 


494 


65280 


493 


65443 


491 


65610 


494 


64764 


494 


64891 


998 


65281 


998 


65444 


494 


65611 


998 


64780 


494 


64892 


998 


65283 


491 


65450 


494 


65613 


492 


64781 


998 


64893 


492 


65290 


493 


65451 


998 


65620 


494 


64782 


998 


64894 


494 


65291 


998 


65452 


998 


65621 


998 


64783 


492 


650 


998 


65293 


491 


65453 


492 


65623 


492 


64784 


494 


65100 


494 


65300 


493 


65454 


494 


65630 


493 


64790 


494 


65101 


998 


65301 


998 


65460 


494 


65631 


998 


64791 


998 


65103 


492 


65303 


492 


65461 


998 


65633 


492 


64792 


998 


65110 


494 


65310 


493 


65462 


998 


65640 


494 


64793 


492 


65111 


998 


65311 


998 


65463 


492 


65641 


998 


64794 


494 


65113 


492 


65313 


492 


65464 


494 


65643 


492 


64800 


494 


65120 


494 


65320 


493 


65470 


494 


65650 


494 


64801 


998 


65121 


998 


65321 


998 


65471 


998 


65651 


998 


64802 


998 


65123 


492 


65323 


492 


65472 


998 


65653 


492 


64803 


492 


65130 


494 


65330 


493 


65473 


492 


65660 


494 


64804 


494 


65131 


998 


65331 


998 


65474 


494 


65661 


998 


64810 


494 


65133 


492 


65333 


492 


65480 


494 


65663 


492 


64811 


998 


65140 


494 


65340 


493 


65481 


998 


65670 


494 


64812 


998 


65141 


998 


65341 


998 


65482 


998 


65671 


998 


64813 


492 


65143 


492 


65343 


492 


65483 


492 


65673 


492 


64814 


494 


65150 


494 


65350 


493 


65484 


494 


65680 


494 


64820 


494 


65151 


998 


65351 


998 


65490 


493 


65681 


998 


64821 


998 


65153 


492 


65353 


492 


65491 


998 


65683 


492 


64822 


998 


65160 


494 


65360 


494 


65492 


998 


65690 


494 


64823 


492 


65161 


998 


65361 


998 


65493 


491 


65691 


998 


64824 


494 


65163 


492 


65363 


492 


65494 


493 


65693 


492 


64830 


494 


65180 


494 


65370 


493 


65500 


494 


65700 


494 


64831 


998 


65181 


998 


65371 


998 


65501 


998 


65701 


998 


64832 


998 


65183 


492 


65373 


492 


65503 


492 


65703 


492 


64833 


492 


65190 


494 


65380 


493 


65510 


494 


65800 


494 


64834 


494 


65191 


998 


65381 


998 


65511 


998 


65801 


998 


64840 


494 


65193 


492 


65383 


492 


65513 


492 


65803 


492 


64841 


998 


65200 


493 


65390 


998 


65520 


494 


65810 


492 


64842 


998 


65201 


998 


65391 


998 


65521 


998 


65811 


998 


64843 


492 


65203 


491 


65393 


492 


65523 


492 


65813 


492 


64844 


494 


65210 


493 


65400 


494 


65530 


494 


65820 


493 


64850 


494 


65211 


998 


65401 


998 


65531 


998 


65821 


492 


64851 


998 


65213 


492 


65402 


998 


65533 


492 


65823 


491 


64852 


998 


65220 


493 


65403 


492 


65540 


494 


65830 


493 


64853 


492 


65221 


998 


65404 


494 


65541 


998 


65831 


998 


64854 


494 


65223 


491 


65410 


494 


65543 


492 


65833 


492 


64860 


494 


65230 


493 


65411 


998 


65550 


494 


65840 


494 


64861 


998 


65231 


998 


65412 


998 


65551 


998 


65841 


998 


216 


















Final Report 



4**' 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


65843 


492 


66073 


492 


66363 


492 


66580 


494 


66904 


494 


65880 


494 


66080 


494 


66380 


493 


66581 


998 


66910 


494 


65881 


998 


66081 


998 


66381 


998 


66582 


998 


66911 


998 


65883 


492 


66083 


492 


66383 


492 


66583 


492 


66912 


998 


65890 


494 


66090 


494 


66390 


493 


66584 


494 


66913 


492 


65891 


494 


66091 


998 


66391 


998 


66590 


494 


66914 


494 


65893 


492 


66093 


492 


66393 


492 


66591 


998 


66920 


494 


65900 


494 


66100 


493 


66400 


493 


66592 


998 


66921 


998 


65901 


998 


66101 


998 


66401 


998 


66593 


492 


66922 


998 


65903 


492 


66103 


492 


66404 


493 


66594 


494 


66923 


492 


65910 


492 


66110 


493 


66410 


493 


66600 


494 


66924 


494 


65911 


998 


66111 


998 


66411 


998 


66602 


998 


66930 


494 


65913 


492 . ■ 


66113 


492 


66414 


493 


66604 


494 


66932 


998 


65920 


494 


66120 


493 


66420 


493 


66610 


494 


66934 


494 


65921 


998 


66121 


998 


66421 


998 


66612 


998 


66940 


494 


65923 


492 


66123 


492 


66424 


493 


66614 


494 


66941 


998 


65930 


494 


66130 


493 


66430 


494 


66620 


494 


66942 


998 


65931 


998 


66131 


998 


66431 


998 


66622 


998 


66943 


681 


65933 


492 


66133 


492 


66434 


494 


66624 


494 


66944 


494 


65940 


493 


66140 


493 


66440 


493 


66630 


494 


66950 


493 


65941 


998 


66141 


998 


66441 


998 


66632 


998 


66951 


998 


65943 


492 


66143 


492 


66444 


493 


66634 


494 


66960 


493 


65950 


493 


66190 


493 


66450 


494 


66700 


494 


66% 1 


998 


65951 


998 


66191 


998 


66451 


998 


66702 


998 


66970 


494 


65953 


492 


66193 


492 


66454 


494 


66704 


494 


66971 


998 


65960 


493 


66200 


493 


66480 


494 


66710 


494 


66980 


998 


65961 


998 


66201 


998 


66481 


998 


66712 


998 


66981 


998 


65963 


492 


66203 


492 


66484 


494 


66714 


494 


66982 


998 


65980 


493 


66210 


493 


66490 


494 


66800 


494 


66983 


492 


65981 


998 


66211 


998 


66491 


998 


66801 


998 


66984 


493 


65983 


492 


66213 


492 


66494 


494 


66802 


998 


66990 


493 


65990 


493 


66220 


493 


66500 


494 


66803 


492 


66991 


998 


65991 


998 


66221 


998 


66501 


998 


66804 


494 


66992 


998 


65993 


492 


66223 


492 


66503 


492 


66810 


494 


66993 


492 


66000 


494 


66230 


493 


66510 


494 


66811 


998 


66994 


493 


66001 


998 


66231 


998 


66511 


998 


66812 


998 


67000 


494 


66003 


492 


66233 


492 


66512 


998 


66813 


492 


67002 


998 


66010 


494 


66300 


493 


66514 


494 


66814 


494 


67004 


494 


66011 


998 


66301 


998 


66520 


493 


66820 


494 


67100 


493 


66013 


492 


66303 


492 


66522 


998 


66821 


998 


67101 


998 


66020 


494 


66310 


493 


66524 


494 


66822 


998 


67102 


998 


66021 


492 


66311 


998 


66530 


493 


66823 


492 


67103 


491 


66023 


492 


66313 


492 


66531 


998 


66824 


494 


67104 


493 


66030 


494 


66320 


493 


66534 


494 


66880 


494 


67110 


493 


66031 


998 


66321 


998 


66540 


493 


66881 


998 


67111 


998 


66033 


492 


66323 


492 


66541 


998 


66882 


998 


67112 


998 


66040 


494 


66330 


493 


66544 


494 


66883 


492 


67113 


491 


6604] 


998 


66331 


998 


66550 


494 


66884 


494 


67114 


493 


66043 


492 


66333 


492 


66551 


998 


66890 


494 


67120 


494 


66050 


494 


66340 


493 


66554 


494 


66891 


998 


67121 


998 


66051 


998 


66341 


998 


66560 


494 


66892 


998 


67122 


998 


66053 


492 


66343 


492 


66561 


998 


66893 


492 


67123 


492 


66060 


494 


66350 


493 


66564 


494 


66894 


494 


67124 


494 


66061 


998 


66351 


998 


66570 


494 


66900 


494 


67130 


494 


66063 


492 


66353 


492 


66571 


998 


66901 


998 


67131 


998 


66070 


494 


66360 


493 


66572 


998 


66902 


998 


67133 


492 


66071 


998 


66361 


998 


66574 


494 


66903 


492 


67140 


494 



The Development of a Physician Prospective Payment System for Ambulatory Care 



217 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


67142 


998 


67432 


998 


67641 


494 


6868 


635 


6970 


635 


67144 


494 


67434 


494 


67642 


494 


6869 


635 


6971 


635 


67150 


494 


67440 


493 


67643 


492 


690 


635 


6978 


635 


67151 


998 


67442 


998 


67644 


494 


69010 


635 


6979 


635 


67152 


998 


67444 


493 


67650 


493 


69011 


635 


6980 


635 


67153 


492 


67480 


494 


67651 


493 


69012 


635 


6981 


672 


67154 


494 


67482 


998 


67652 


493 


69018 


635 


6982 


635 


67180 


493 


67484 


494 


67653 


492 


6908 


635 


6983 


635 


67181 


998 


67490 


494 


67654 


493 


6910 


635 


6984 


635 


67182 


998 


67492 


998 


67660 


493 


6918 


635 


6988 


635 


67183 


491 


67494 


494 


67661 


493 


6920 


635 


6989 


635 


67184 


493 


67500 


494 


67662 


493 


6921 


635 


700 


631 


67190 


494 ' 


67501 


494 


67663 


492 


6922 


635 


7010 


635 


67191 


998 


67502 


494 


67664 


493 


6923 


635 


7011 


635 


67192 


998 


67503 


492 


67680 


494 


6924 


635 


7012 


635 


67193 


492 


67504 


494 


67681 


494 


6925 


635 


7013 


635 


67194 


494 


67510 


494 


67682 


494 


6926 


635 


7014 


635 


67200 


493 


67511 


494 


67683 


492 


69270 


635 


7015 


635 


67202 


998 


67512 


494 


67684 


494 


69271 


635 


7018 


635 


67204 


494 


67513 


492 


67690 


494 


69272 


635 


7019 


635 


67300 


494 


67514 


494 


67691 


494 


69273 


635 


7020 


635 


67301 


998 


67520 


494 


67692 


494 


69274 


635 


7021 


635 


67302 


998 


67521 


494 


67693 


492 


69279 


635 


70211 


635 


67303 


492 


67522 


494 


67694 


494 


69281 


635 


70219 


635 


67304 


494 


67523 


492 


677 


705 


69282 


635 


7028 


635 


67310 


494 


67524 


494 


6800 


633 


69283 


635 


7030 


631 


67311 


998 


67580 


494 


6801 


633 


69289 


635 


7038 


631 


67312 


998 


67581 


494 


6802 


633 


6929 


635 


7039 


631 


67313 


492 


67582 


494 


6803 


633 


6930 


635 


70400 


635 


67314 


494 


67583 


492 


6804 


633 


6931 


635 


70401 


635 


67320 


494 


67584 


494 


6805 


633 


6938 


635 


70402 


635 


67321 


998 


67590 


494 


6806 


633 


6939 


635 


70409 


635 


67322 


998 


67591 


494 


6807 


633 


6940 


635 


7041 


635 


67323 


492 


67592 


494 


6808 


633 


6941 


534 


7042 


635 


67324 


494 


67593 


492 


6809 


633 


6942 


636 


7043 


635 


67330 


494 


67594 


494 


68100 


633 


6943 


636 


7048 


635 


67331 


998 


67600 


494 


68101 


633 


6944 


636 


7049 


635 


67332 


998 


67601 


494 


68102 


635 


6945 


636 


7050 


635 


67333 


492 


67602 


494 


68110 


633 


69460 


635 


7051 


635 


67334 


494 


67603 


491 


68111 


633 


69461 


636 


70581 


635 


67380 


494 


67604 


494 


6819 


633 


6948 


636 


70582 


635 


67381 


998 


67610 


494 


6820 


633 


6949 


636 


70583 


635 


67382 


998 


67611 


494 


6821 


633 


6950 


636 


70589 


635 


67383 


492 


67612 


494 


6822 


633 


6951 


635 


7059 


635 


67384 


494 


67613 


491 


6823 


633 


6952 


635 


7060 


635 


67400 


494 


67614 


494 


6824 


633 


6953 


635 


7061 


635 


67401 


998 


67620 


494 


6825 


633 


6954 


636 


7062 


635 


67402 


998 


67621 


494 


6826 


633 


69581 


635 


7063 


635 


67403 


492 


67622 


494 


6827 


633 


69589 


635 


7068 


635 


67404 


494 


67623 


491 


6828 


633 


6959 


635 


7069 


635 


67410 


494 


67624 


494 


6829 


633 


6960 


628 


7070 


632 


67412 


998 


67630 


494 


683 


693 


6961 


635 


7071 


632 


67414 


494 


67631 


494 


684 


633 


6962 


635 


7078 


632 


67420 


494 


67632 


494 


6850 


635 


6963 


635 


7079 


632 


67422 


998 


67633 


492 


6851 


635 


6964 


635 


7080 


635 


67424 


494 


67634 


494 


6860 


635 


6965 


635 


7081 


635 


67430 


494 


67640 


494 


6861 


635 


6968 


635 


7082 


635 


218 


















Final Report 



n\e 















1 


Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


7083 


635 


71134 


628 


71191 


628 


71298 


622 


71593 


622 


7084 


635 


71135 


628 


71192 


628 


71299 


622 


71594 


622 


7085 


635 


71136 


628 


71193 


628 


7130 


622 


71595 


622 


7088 


635 


71137 


628 


71194 


628 


7131 


622 


71596 


622 


7089 


635 


71138 


628 


71195 


628 


7132 


622 


71597 


622 


7090 


635 


71139 


628 


71196 


628 


7133 


622 


71598 


622 


70900 


635 


71140 


628 


71197 


628 


7134 


622 


71600 


628 


70901 


635 


71141 


628 


71198 


628 


7135 


628 


71601 


628 


70909 


635 


71142 


628 


71199 


628 


7136 


622 


71602 


628 


7091 


635 


71143 


628 


71210 


622 


7137 


622 


71603 


628 


7092 


635 


71144 


628 


71211 


622 


7138 


622 


71604 


628 


7093 


635 . 


71145 


628 


71212 


622 


7140 


622 


71605 


628 


7094 


635 . ■ 


71146 


628 


71213 


622 


7141 


628 


71606 


628 


7098 


635 


71147 


628 


71214 


622 


7142 


628 


71607 


628 


7099 


635 


71148 


628 


71215 


622 


71430 


628 


71608 


628 


7100 


693 


71149 


628 


71216 


622 


71431 


628 


71609 


628 


7101 


693 


71150 


628 


71217 


622 


71432 


628 


71610 


628 


7102 


694 


71151 


628 


71218 


622 


71433 


628 


71611 


678 


7103 


694 


71152 


628 


71219 


622 


7144 


622 


71612 


628 


7104 


694 


71153 


628 


71220 


622 


71481 


563 


71613 


628 


7105 


622 


71154 


628 


71221 


622 


71489 


622 


71614 


628 


7108 


622 


71155 


628 


71222 


622 


7149 


622 


71615 


628 


7109 


622 


71156 


628 


71223 


622 


71500 


622 


71616 


628 


71100 


628 


71157 


628 


71224 


622 


71504 


622 


71617 


628 


71101 


628 


71158 


628 


71225 


622 


71509 


622 


71618 


628 


71102 


628 


71159 


628 


71226 


622 


71510 


622 • 


71619 


628 


71103 


628 


71160 


628 


71227 


622 


71511 


622 


71620 


622 


71104 


628 


71161 


628 


71228 


622 


71512 


622 


71621 


622 


71105 


628 


71162 


628 


71229 


622 


71513 


622 


71622 


622 


71106 


628 


71163 


628 


71230 


622 


71514 


622 


71623 


622 


71107 


628 


71164 


628 


71231 


622 


71515 


622 


71624 


622 


71108 


628 


71165 


628 


71232 


622 


71516 


622 


71625 


622 


71109 


628 


71166 


628 


71233 


622 


71517 


622 


71626 


622 


71110 


622 


71167 


628 


71234 


622 


71518 


622 


71627 


622 


71111 


622 


71168 


628 


71235 


622 


71520 


622 


71628 


622 


71112 


622 


71169 


628 


71236 


622 


71521 


622 


71629 


622 


71113 


622 


71170 


628 


71237 


622 


71522 


622 


71630 


622 


71114 


622 


71171 


628 


71238 


622 


71523 


622 


71631 


622 


71115 


622 


71172 


628 


71239 


622 


71524 


622 


71632 


622 


71116 


622 


71173 


628 


71280 


622 


71525 


622 


71633 


622 


71117 


622 


71174 


628 


71281 


622 


71526 


622 


71634 


622 


71118 


622 


71175 


628 


71282 


622 


71527 


622 


71635 


622 


71119 


622 


71176 


628 


71283 


622 


71528 


622 


71636 


622 


71120 


628 


71177 


628 


71284 


622 


71530 


622 


71637 


622 


71121 


628 


71178 


628 


71285 


622 


71531 


622 


71638 


622 


71122 


628 


71179 


628 


71286 


622 


71532 


622 


71639 


622 


71123 


628 


71180 


628 


71287 


622 


71533 


622 


71640 


622 


71124 


628 


71181 


628 


71288 


622 


71534 


622 


71641 


622 


71125 


628 


71182 


628 


71289 


622 


71535 


622 


71642 


622 


71126 


628 


71183 


628 


71290 


622 


71536 


622 


71643 


622 


71127 


628 


71184 


628 


71291 


622 


71537 


622 


71644 


622 


71128 


628 


71185 


628 


71292 


622 


71538 


622 


71645 


622 


71129 


628 


71186 


628 


71293 


622 


71580 


622 


71646 


622 


71130 


628 


71187 


628 


71294 


622 


71589 


622 


71647 


622 


71131 


628 


71188 


628 


71295 


622 


71590 


622 


71648 


622 


71132 


628 


71189 


628 


71296 


622 


71591 


622 


71649 


622 


71133 


628 


71190 


628 


71297 


622 


71592 


622 


71650 


622 



The Development of a Physician Prospective Payment System for Ambulatory Care 



219 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


7I65I 


622 


71800 


622 


71859 


622 


71935 


622 


71996 


622 


71652 


622 


71801 


622 


71860 


622 


71936 


622 


71997 


622 


71653 


622 


71802 


622 


71865 


622 


71937 


622 


71998 


622 


71654 


622 


71803 


622 


71880 


622 


71938 


622 


71999 


622 


71655 


622 


71804 


622 


71881 


622 


71939 


622 


7200 


628 


71656 


622 


71805 


622 


71882 


622 


71940 


622 


7201 


628 


71657 


622 


71807 


622 


71883 


622 


71941 


622 


7202 


621 


71658 


622 


71808 


622 


71884 


622 


71942 


622 


72081 


622 


71659 


622 


71809 


622 


71885 


622 


71943 


622 


72089 


628 


71660 


622 


71810 


622 


71886 


622 


71944 


622 


7209 


628 


71661 


622 


71811 


622 


71887 


622 


71945 


622 


7210 


628 


71662 


622 


71812 


622 


71888 


622 


71946 


622 


7211 


628 


71663 


622 


71813 


622 


71889 


622 


71947 


622 


7212 


628 


71664 


622 


71814 


622 


71890 


622 


71948 


622 


7213 


621 


71665 


622 


71815 


622 


71891 


622 


71949 


622 


72141 


628 


71666 


622 


71817 


622 


71892 


622 


71950 


622 


72142 


628 


71667 


622 


71818 


622 


71893 


622 


71951 


622 


7215 


628 


71668 


622 


71819 


622 


71894 


622 


71952 


622 


7216 


628 


71680 


622 


71820 


628 


71895 


622 


71953 


622 


7217 


628 


71681 


622 


71821 


628 


71897 


622 


71954 


622 


7218 


628 


71682 


622 


71822 


628 


71898 


622 


71955 


622 


72190 


628 


71683 


622 


71823 


628 


71899 


622 


71956 


622 


72191 


628 


71684 


622 


71824 


628 


71900 


628 


71957 


622 


7220 


628 


71685 


622 


71825 


628 


71901 


628 


71958 


622 


72210 


621 


71686 


622 


71826 


628 


71902 


628 


71959 


622 


72211 


628 


71687 


622 


71827 


628 


71903 


628 


71960 


622 


7222 


621 


71688 


622 


71828 


628 


71904 


628 


71961 


622 


72230 


622 


71689 


622 


71829 


628 


71905 


628 


71962 


622 


72231 


622 


71690 


622 


71830 


628 


71906 


628 


71963 


622 


72232 


621 


71691 


622 


71831 


628 


71907 


628 


71964 


622 


72239 


622 


71692 


622 


71832 


628 


71908 


628 


71965 


622 


7224 


628 


71693 


622 


71833 


628 


71909 


628 


71966 


622 


72251 


628 


71694 


622 


71834 


628 


71910 


628 


71967 


622 


72252 


621 


71695 


622 


71835 


622 


71911 


628 


71968 


622 


7226 


622 


71696 


622 


71836 


622 


71912 


628 


71%9 


622 


72270 


622 


71697 


622 


71837 


622 


71913 


628 


71970 


622 


72271 


628 


71698 


622 


71838 


622 


71914 


628 


71975 


622 


72272 


628 


71699 


622 


71839 


622 


71915 


628 


71976 


622 


72273 


628 


7170 


622 


71840 


622 


71916 


628 


71977 


622 


72280 


622 


7171 


622 


71841 


622 


71917 


628 


71978 


622 


72281 


622 


7172 


622 


71842 


622 


71918 


628 


71979 


622 


72282 


622 


7173 


622 


71843 


622 


71919 


628 


71980 


622 


72283 


621 


71740 


622 


71844 


622 


71920 


628 


71981 


622 


72290 


622 


71741 


622 


71845 


622 


71921 


628 


71982 


622 


72291 


622 


71742 


622 


71846 


622 


71922 


628 


71983 


622 


72292 


622 


71743 


622 


71847 


622 


71923 


628 


71984 


622 


72293 


621 


71749 


622 


71848 


622 


71924 


628 


71985 


622 


7230 


628 


7175 


622 


71849 


622 


71925 


628 


71986 


622 


7231 


622 


7176 


622 


71850 


622 


71926 


628 


71987 


622 


7232 


515 


7177 


622 


71851 


622 


71927 


628 


71988 


622 


7233 


515 


71781 


622 


71852 


622 


71928 


628 


71989 


622 


7234 


515 


71782 


622 


71853 


622 


71929 


628 


71990 


622 


7235 


628 


71783 


622 


71854 


622 


71930 


622 


71991 


622 


7236 


635 


71784 


622 


71855 


622 


71931 


622 


71992 


622 


7237 


622 


71785 


622 


71856 


622 


71932 


622 


71993 


622 


7238 


622 


71789 


622 


71857 


622 


71933 


622 


71994 


622 


7239 


622 


7179 


622 


71858 


622 


71934 


622 


71995 


622 


72400 


628 


220 


















Final Report 



-S?!K, 

















Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


72401 


628 


72743 


622 


73004 


628 


73091 


622 


734 


622 


72402 


628 


72749 


622 


73005 


628 


73092 


622 


7350 


622 


72409 


628 


72750 


622 


73006 


628 


73093 


622 


7351 


622 


7241 


621 


72751 


622 


73007 


628 


73094 


622 


7352 


622 


7242 


621 


72759 


622 


73008 


628 


73095 


622 


7353 


622 


7243 


628 


72760 


622 


73009 


628 


73096 


622 


7354 


622 


7244 


621 


72761 


622 


73010 


628 


73097 


622 


7355 


622 


7245 


621 


72762 


622 


73011 


628 


73098 


622 


7358 


622 


7246 


621 


72763 


622 


73012 


628 


73099 


622 


7359 


622 


72470 


621 


72764 


622 


73013 


628 


7310 


622 


73600 


622 


72471 


621 


72765 


622 


73014 


628 


7311 


622 


73601 


622 


72479 


621 . 


72766 


622 


73015 


628 


7312 


622 


73602 


622 


7248 


621 ." 


72767 


622 


73016 


628 


7318 


622 


73603 


622 


7249 


621 


72768 


622 


73017 


628 


7320 


622 


73604 


622 


725 


628 


72769 


622 


73018 


628 


7321 


622 


73605 


515 


7260 


622 


72781 


622 


73019 


628 


7322 


622 


73606 


515 


72610 


622 


72782 


622 


73020 


628 


7323 


622 


73607 


515 


72611 


622 


72789 


622 


73021 


628 


7324 


622 


73609 


622 


72612 


622 


7279 


622 


73022 


628 


7325 


622 


7361 


622 


72619 


622 


7280 


628 


73023 


628 


7326 


622 


73620 


622 


7262 


622 


72810 


628 


73024 


628 


7327 


622 


73621 


622 


72630 


628 


72811 


628 


73025 


628 


7328 


622 


73622 


622 


72631 


622 


72812 


628 


73026 


628 


7329 


622 


73629 


622 


72632 


622 


72813 


622 


73027 


628 


73300 


622 


73630 


622 


72633 


622 


72819 


622 


73028 


628 


73301 


622 


73631 


622 


72639 


628 


7282 


622 


73029 


628 


73302 


622 


73632 


622 


7264 


628 


7283 


622 


73030 


622 


73303 


622 


73639 


622 


7265 


622 


7284 


622 


73031 


622 


73309 


622 


73641 


622 


72660 


622 


7285 


622 


73032 


622 


7331 


464 


73642 


622 


72661 


622 


7286 


622 


73033 


622 


73310 


464 


7365 


622 


72662 


622 


72871 


622 


73034 


622 


73311 


464 


7366 


622 


72663 


622 


72879 


622 


73035 


622 


73312 


464 


73670 


622 


72664 


622 


72881 


622 


73036 


622 


73313 


464 


73671 


622 


72665 


622 


72882 


622 


73037 


622 


73314 


464 


73672 


622 


72669 


628 


72883 


622 


73038 


622 


73315 


464 


73673 


622 


72670 


622 


72884 


622 


73039 


622 


73316 


464 


73674 


515 


72671 


622 


72885 


622 


73070 


622 


73319 


464 


73675 


622 


72672 


622 


72886 


502 


73071 


622 


73320 


622 


73676 


622 


72673 


622 


72889 


622 


73072 


622 


73321 


622 


73679 


622 


72679 


622 


7289 


622 


73073 


622 


73322 


622 


73681 


622 


7268 


628 


7290 


622 


73074 


622 


73329 


622 


73689 


622 


72690 


622 


7291 


622 


73075 


622 


7333 


622 


7369 


622 


72691 


622 


7292 


515 


73076 


622 


73340 


628 


7370 


622 


72700 


622 


72930 


635 


73077 


622 


73341 


628 


73710 


622 


72701 


622 


72931 


635 


73078 


622 


73342 


628 


73711 


628 


72702 


622 


72939 


635 


73079 


622 


73343 


628 


73712 


628 


72703 


622 


7294 


622 


73080 


622 


73344 


628 


73719 


622 


72704 


622 


7295 


622 


73081 


622 


73349 


628 


73720 


622 


72705 


622 


7296 


462 


73082 


622 


7335 


628 


73721 


622 


72706 


622 


72981 


622 


73083 


622 


7336 


563 


73722 


622 


72709 


622 


72982 


622 


73084 


622 


7337 


628 


73729 


622 


7271 


622 


72989 


622 


73085 


622 


73381 


464 


73730 


622 


7272 


622 


7299 


622 


73086 


622 


73382 


464 


73731 


622 


7273 


622 


73000 


628 


73087 


622 


73390 


622 


73732 


628 


72740 


622 


73001 


628 


73088 


622 


73391 


622 


73733 


628 


72741 


622 


73002 


628 


73089 


622 


73392 


622 


73734 


628 


72742 


622 


73003 


628 


73090 


622 


73399 


628 


73739 


628 



The Development of a Physician Prospective Payment System for Ambulatory Care 



221 



APPENDIX F 


















DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


73740 


622 


74321 


534 


74449 


545 


74760 


576 


7507 


596 


73741 


622 


74322 


534 


7445 


635 


74761 


576 


7508 


596 


73742 


622 


74330 


531 


74481 


545 


74762 


576 


7509 


596 


73743 


622 


74331 


531 


74482 


545 


74763 


576 


7510 


596 


7378 


622 


74332 


531 


74483 


545 


74764 


576 


7511 


597 


7379 


622 


74333 


531 


74484 


545 


74769 


576 


7512 


597 


7380 


544 


74334 


531 


74489 


545 


74781 


705 


7513 


597 


73810 


622 


74335 


531 


7449 


635 


74782 


576 


7514 


596 


73811 


622 


74336 


531 


7450 


576 


74789 


575 


7515 


596 


73812 


622 


74337 


531 


74510 


576 


7479 


705 


75160 


593 


73819 


622 


74339 


531 


74511 


576 


7480 


545 


75161 


593 


7382 


622 . 


74341 


534 


74512 


576 


7481 


544 


75162 


593 


7383 


622 , ■ 


74342 


534 


74519 


576 


7482 


545 


75169 


593 


7384 


622 


74343 


534 


7452 


576 


7483 


545 


7517 


593 


7385 


622 


74344 


534 


7453 


576 


7484 


564 


7518 


596 


7386 


622 


74345 


534 


7454 


575 


7485 


564 


7519 


596 


7387 


544 


74346 


534 


7455 


576 


74860 


564 


7520 


681 


7388 


622 


74347 


534 


74560 


576 


74861 


564 


75210 


681 


7389 


622 


74348 


534 


74561 


576 


74869 


564 


75211 


681 


7390 


622 


74349 


534 


74569 


576 


7488 


705 


75219 


681 


7391 


622 


74351 


534 


7457 


576 


7489 


705 


7522 


681 


7392 


622 


74352 


534 


7458 


575 


74900 


545 


7523 


681 


7393 


622 


74353 


534 


7459 


575 


74901 


545 


75240 


681 


7394 


622 


74354 


534 


74600 


575 


74902 


545 


75241 


681 


7395 


622 


74355 


534 


74601 


576 


74903 


545 


75242 


681 


7396 


622 


74356 


534 


74602 


576 


74904 


545 • 


75249 


681 


7397 


622 


74357 


534 


74609 


576 


74910 


545 


7525 


672 


7398 


622 


74358 


534 


7461 


576 


74911 


545 


7526 


672 


7399 


622 


74359 


534 


7462 


576 


74912 


545 


7527 


672 


7400 


516 


74361 


534 


7463 


575 


74913 


545 


7528 


672 


7401 


516 


74362 


534 


7464 


575 


74914 


545 


7529 


672 


7402 


516 


74363 


534 


7465 


575 


74920 


545 


7530 


665 


74100 


516 


74364 


534 


7466 


575 


74921 


545 


75310 


G 


74101 


516 


74365 


534 


7467 


576 


74922 


545 


75311 


G 


74102 


516 


74366 


534 


74681 


576 


74923 


545 


75312 


665 


74103 


516 


74369 


534 


74682 


576 


74924 


545 


75313 


665 


74190 


516 


7438 


534 


74683 


576 


74925 


545 


75314 


665 


74191 


516 


7439 


534 


74684 


576 


7500 


544 


75315 


665 


74192 


516 


74400 


544 


74685 


576 


75010 


544 


75316 


665 


74193 


516 


74401 


545 


74686 


576 


75011 


544 


75317 


665 


7420 


516 


74402 


545 


74687 


576 


75012 


544 


75319 


665 


7421 


516 


74403 


545 


74689 


575 


75013 


544 


7532 


665 


7422 


516 


74404 


545 


7469 


575 


75015 


544 


7533 


665 


7423 


516 


74405 


545 


7470 


576 


75016 


544 


7534 


G 


7424 


516 


74409 


545 


74710 


576 


75019 


544 


7535 


G 


74251 


516 


7441 


545 


74711 


575 


75021 


544 


7536 


665 


74253 


516 


74421 


545 


74720 


575 


75022 


544 


7537 


665 


74259 


516 


74422 


545 


74721 


575 


75023 


544 


7538 


665 


7428 


515 


74423 


545 


74722 


576 


75024 


544 


7539 


665 


7429 


515 


74424 


545 


74729 


575 


75025 


544 


7540 


622 


74300 


534 


74429 


545 


7473 


575 


75026 


705 


7541 


622 


74303 


534 


7443 


545 


74740 


575 


75027 


544 


7542 


622 


74306 


534 


74441 


545 


74741 


576 


75029 


705 


75430 


622 


74310 


534 


74442 


545 


74742 


576 


7503 


597 


75431 


622 


74311 


534 


74443 


545 


74749 


576 


7504 


597 


75432 


622 


74312 


534 


74446 


545 


7475 


576 


7505 


597 


75433 


622 


74320 


534 


74447 


545 


7476 


575 


7506 


596 


75435 


622 


222 


















Final Report 



i,V> 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


75440 


622 


75558 


628 


7584 


705 


7631 


481 


76508 


481 


75441 


622 


75559 


622 


7585 


705 


7632 


481 


76509 


481 


75442 


622 


75560 


622 


7586 


672 


7633 


481 


76510 


481 


75443 


622 


75561 


622 


7587 


672 


7634 


481 


76511 


481 


75444 


622 


75562 


622 


7588 


672 


7635 


481 


76512 


481 


75450 


622 


75563 


622 


7589 


481 


7636 


481 


76513 


481 


75451 


622 


75564 


622 


7590 


693 


7637 


481 


76514 


481 


75452 


622 


75565 


628 


7591 


652 


7638 


481 


76515 


481 


75453 


622 


75566 


622 


7592 


652 


7639 


481 


76516 


481 


75459 


622 


75567 


622 


7593 


596 


76400 


481 


76517 


481 


75460 


622 


75569 


622 


7594 


481 


76401 


481 


76518 


481 


75461 


622 . 


7558 


622 


7595 


516 


76402 


481 


76519 


481 


75462 


622 . ■ 


7559 


622 


7596 


635 


76403 


481 


7660 


481 


75469 


622 


7560 


622 


7597 


481 


76404 


481 


7661 


481 


75470 


622 


75610 


622 


75981 


481 


76405 


481 


7662 


481 


75471 


622 


75611 


622 


75982 


481 


76406 


481 


7670 


481 


75479 


622 


75612 


622 


75983 


653 


76407 


481 


7671 


481 


75481 


705 


75613 


628 


75989 


481 


76408 


481 


7672 


481 


75482 


705 


75614 


628 


7599 


481 


76409 


481 


7673 


481 


75489 


622 


75615 


628 


7600 


481 


76410 


481 


7674 


481 


75500 


628 


75616 


628 


7601 


481 


76411 


481 


7675 


481 


75501 


628 


75617 


515 


7602 


481 


76412 


481 


7676 


481 


75502 


628 


75619 


622 


7603 


481 


76413 


481 


7677 


481 


75510 


628 


7562 


622 


7604 


481 


76414 


481 


7678 


481 


75511 


628 


7563 


705 


7605 


481 


76415 


481 


7679 


481 


75512 


628 


7564 


622 


7606 


481 


76416 


481 


7680 


481 


75513 


628 


75650 


622 


76070 


481 


76417 


481 


7681 


481 


75514 


628 


75651 


628 


76071 


481 


76418 


481 


7682 


481 


75520 


628 


75652 


628 


76072 


481 


76419 


481 


7683 


481 


75521 


628 


75653 


628 


76073 


481 


76420 


481 


7684 


481 


75522 


628 


75654 


622 


76074 


481 


76421 


481 


7685 


481 


75523 


628 


75655 


628 


76075 


481 


76422 


481 


7686 


481 


75524 


628 


75656 


628 


76076 


681 


76423 


481 


7689 


481 


75525 


628 


75659 


622 


76079 


481 


76424 


481 


769 


481 


75526 


628 


7566 


705 


7608 


481 


76425 


481 


7700 


481 


75527 


628 


7567 


596 


7609 


481 


76426 


481 


7701 


481 


75528 


628 


75681 


622 


7610 


481 


76427 


481 


7702 


481 


75529 


628 


75682 


622 


7611 


481 


76428 


481 


7703 


481 


75530 


628 


75683 


628 


7612 


481 


76429 


481 


7704 


481 


75531 


628 


75689 


622 


7613 


481 


76490 


481 


7705 


481 


75532 


628 


7569 


622 


7614 


481 


76491 


481 


7706 


481 


75533 


628 


7570 


635 


7615 


481 


76492 


481 


7707 


481 


75534 


628 


7571 


636 


7616 


481 


76493 


481 


7708 


481 


75535 


628 


7572 


636 


7617 


481 


76494 


481 


7709 


481 


75536 


628 


75731 


636 


7618 


481 


76495 


481 


7710 


481 


75537 


628 


75732 


636 


7619 


481 


76496 


481 


7711 


481 


75538 


628 


75733 


636 


7620 


481 


76497 


481 


T712 


481 


75539 


628 


75739 


635 


7621 


481 


76498 


481 


7713 


481 


7554 


628 


7574 


635 


7622 


481 


76499 


481 


7714 


481 


75550 


628 


7575 


631 


7623 


481 


76500 


481 


7715 


481 


75551 


628 


7576 


634 


7624 


481 


76501 


481 


7716 


481 


75552 


628 


7578 


635 


7625 


481 


76502 


481 


7717 


481 


75553 


628 


7579 


635 


7626 


481 


76503 


481 


7718 


481 


75554 


628 


7580 


296 


7627 


481 


76504 


481 


7720 


481 


75555 


628 


7581 


296 


7628 


481 


76505 


481 


7721 


481 


75556 


628 


7582 


296 


7629 


481 


76506 


481 


7722 


481 


75557 


628 


7583 


296 


7630 


481 


76507 


481 


7723 


481 



The Development of a Physician Prospective Payment System for Ambulatory Care 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


7724 


481 


7788 


481 


7834 


653 


78799 


596 


78946 


596 


7725 


481 


7789 


481 


7835 


653 


7880 


665 


78947 


596 


7726 


481 


7790 


481 


7836 


652 


7881 


G 


78949 


596 


7728 


481 


7791 


481 


7839 


652 


7882 


665 


7895 


593 


7729 


481 


7792 


481 


7840 


512 


78820 


G 


78960 


5% 


7730 


481 


7793 


481 


7841 


705 


78821 


G 


78961 


596 


7731 


481 


7794 


481 


7842 


705 


78829 


G 


78962 


596 


7732 


481 


7795 


481 


7843 


515 


78830 


G 


78963 


596 


7733 


481 


7796 


998 


78440 


705 


78831 


G 


78964 


596 


7734 


481 


7798 


481 


78441 


705 


78832 


G 


78965 


5% 


7735 


481 


7799 


481 


78449 


705 


78833 


G 


78966 


596 


7740 


481 . 


78001 


611 


7845 


705 


78834 


G 


78%7 


596 


7741 


481. ■^ 


78002 


515 


78460 


B 


78835 


G 


78969 


596 


7742 


481 


78003 


611 


78461 


B 


78836 


G 


7899 


705 


77430 


481 


78009 


515 


78469 


B 


78837 


G 


7900 


693 


77431 


481 


7801 


B 


7847 


545 


78839 


G 


7901 


705 


77439 


481 


7802 


514 


7848 


596 


7884 


G 


7902 


705 


7744 


481 


7803 


514 


7849 


705 


78841 


G 


7903 


B 


7745 


481 


7804 


705 


7850 


575 


78842 


G 


7904 


705 


7746 


481 


78050 


B 


7851 


575 


78843 


G 


7905 


705 


7747 


481 


78051 


516 


7852 


575 


7885 


662 


7906 


705 


7750 


481 


78052 


B 


7853 


575 


7886 


G 


7907 


502 


7751 


481 


78053 


516 


7854 


575 


78861 


G 


7908 


501 


7752 


481 


78054 


B 


78550 


611 


78862 


G 


7909 


705 


7753 


481 


78055 


B 


78551 


611 


78869 


G 


79091 


705 


7754 


481 


78056 


B 


78559 


502 


7887 


A 


79092 


705 


7755 


481 


78057 


B 


7856 


693 


7888 


665 


79093 


705 


7756 


481 


78059 


B 


7859 


575 


7889 


G 


79099 


705 


7757 


481 


7806 


502 


78600 


563 


7890 


596 


7910 


G 


7758 


481 


7807 


705 


78601 


705 


78900 


596 


7911 


611 


7759 


481 


7808 


721 


78602 


575 


78901 


596 


7912 


G 


7760 


481 


7809 


705 


78609 


564 


78902 


5% 


7913 


G 


7761 


481 


7810 


515 


7861 


564 


78903 


596 


7914 


G 


7762 


481 


7811 


515 


7862 


544 


78904 


596 


7915 


G 


7763 


481 


7812 


515 


7863 


563 


78905 


596 


7916 


G 


7764 


481 


7813 


705 


7864 


705 


78906 


596 


7917 


G 


7765 


481 


7814 


515 


78650 


574 


78907 


596 


7919 


G 


7766 


481 


7815 


564 


78651 


574 


78909 


596 


7920 


705 


7767 


481 


7816 


611 


78652 


574 


7891 


597 


7921 


705 


7768 


481 


7817 


653 


78659 


574 


7892 


694 


7922 


672 


7769 


481 


7818 


515 


7866 


628 


7893 


705 


7923 


492 


7771 


481 


7819 


705 


7867 


705 


78930 


597 


7924 


705 


7772 


481 


7820 


705 


7868 


705 


78931 


597 


7929 


705 


7773 


481 


7821 


635 


7869 


705 


78932 


597 


7930 


705 


7774 


481 


7822 


705 


7870 


596 


78933 


597 


7931 


705 


7775 


48] 


7823 


705 


78701 


5% 


78934 


597 


7932 


705 


7776 


481 


7824 


593 


78702 


596 


78935 


597 


7933 


593 


7778 


481 


7825 


575 


78703 


596 


78936 


597 


7934 


705 


7779 


481 


78261 


705 


7871 


596 


78937 


597 


7935 


G 


7780 


481 


78262 


705 


7872 


596 


78939 


597 


7936 


705 


7781 


481 


7827 


693 


7873 


5% 


7894 


596 


7937 


705 


7782 


481 


7828 


705 


7874 


596 


78940 


596 


7938 


634 


7783 


481 


7829 


705 


7875 


596 


78941 


5% 


7939 


705 


7784 


481 


7830 


596 


7876 


597 


78942 


596 


79400 


705 


7785 


481 


7831 


652 


7877 


5% 


78943 


596 


79401 


705 


7786 


481 


7832 


652 


7879 


705 


78944 


596 


79402 


705 


7787 


481 


7833 


596 


78791 


5% 


78945 


596 


79409 


705 


224 


















Final Report 



*^ 















Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


79410 


705 


80011 


460 


80082 


460 


80153 


460 


80238 


464 


79411 


534 


80012 


460 


80083 


460 


80154 


460 


80239 


464 


79412 


534 


80013 


460 


80084 


460 


80155 


460 


8024 


464 


79413 


534 


80014 


460 


80085 


460 


80156 


460 


8025 


464 


79414 


534 


80015 


460 


80086 


460 


80159 


460 


8026 


464 


79415 


543 


80016 


460 


80089 


460 


80160 


460 


8027 


464 


79416 


705 


80019 


460 


80090 


460 


80161 


460 


8028 


464 


79417 


628 


80020 


460 


80091 


460 


80162 


460 


8029 


464 


79419 


705 


80021 


460 


80092 


460 


80163 


460 


80300 


460 


7942 


705 


80022 


460 


80093 


460 


80164 


460 


80301 


460 


79430 


705 


80023 


460 


80094 


460 


80165 


460 


80302 


460 


79431 


705 . 


80024 


460 


80095 


460 


80166 


460 


80303 


460 


79439 


705/ 


80025 


460 


80096 


460 


80169 


460 


80304 


460 


7944 


G 


80026 


460 


80099 


460 


80170 


460 


80305 


460 


7945 


652 


80029 


460 


80100 


460 


80171 


460 


80306 


460 


7946 


652 


80030 


460 


80101 


460 


80172 


460 


80309 


460 


7947 


652 


80031 


460 


80102 


460 


80173 


460 


80310 


460 


7948 


593 


80032 


460 


80103 


460 


80174 


460 


80311 


460 


7949 


G 


80033 


460 


80104 


460 


80175 


460 


80312 


460 


7950 


681 


80034 


460 


80105 


460 


80176 


460 


80313 


460 


7951 


681 


80035 


460 


80106 


460 


80179 


460 


80314 


460 


7952 


481 


80036 


460 


80109 


460 


80180 


460 


80315 


460 


7953 


501 


80039 


460 


80110 


460 


80181 


460 


80316 


460 


7954 


705 


80040 


460 


80111 


460 


80182 


460 


80319 


460 


7955 


705 


80041 


460 


80112 


460 


80183 


460 


80320 


460 


7956 


705 


80042 


460 


80113 


460 


80184 


460 


80321 


460 


7957 


693 


80043 


460 


80114 


460 


80185 


460 


80322 


460 


79571 


691 


80044 


460 


80115 


460 


80186 


460 


80323 


460 


79579 


693 


80045 


460 


80116 


460 


80189 


460 


80324 


460 


7958 


691 


80046 


460 


80119 


460 


80190 


460 


80325 


460 


7960 


705 


80049 


460 


80120 


460 


80191 


460 


80326 


460 


7961 


705 


80050 


460 


80121 


460 


80192 


460 


80329 


460 


7962 


575 


800S1 


460 


80122 


460 


80193 


460 


80330 


460 


7963 


575 


80052 


460 


80123 


460 


80194 


460 


80331 


460 


7964 


705 


80053 


460 


80124 


460 


80195 


460 


80332 


460 


7969 


705 


80054 


460 


80125 


460 


80196 


460 


80333 


460 


797 


B 


80055 


460 


80126 


460 


80199 


460 


80334 


460 


7980 


721 


80056 


460 


80129 


460 


8020 


464 


80335 


460 


7981 


721 


80059 


460 


80130 


460 


8021 


464 


80336 


460 


7982 


721 


80060 


460 


80131 


460 


80220 


464 


80339 


460 


7989 


721 


80061 


460 


80132 


460 


80221 


464 


80340 


460 


7990 


611 


80062 


460 


80133 


460 


80222 


464 


80341 


460 


7991 


611 


80063 


460 


80134 


460 


80223 


464 


80342 


460 


7992 


B 


80064 


460 


80135 


460 


80224 


464 


80343 


460 


7993 


705 


80065 


460 


80136 


460 


80225 


464 


80344 


460 


7994 


596 


80066 


460 


80139 


460 


80226 


464 


80345 


460 


7998 


705 


80069 


460 


80140 


460 


80227 


464 


80346 


460 


7999 


705 


80070 


460 


80141 


460 


80228 


464 


80349 


460 


80000 


460 


80071 


460 


80142 


460 


80229 


464 


80350 


460 


80001 


460 


80072 


460 


80143 


460 


80230 


464 


80351 


460 


80002 


460 


80073 


460 


80144 


460 


80231 


464 


80352 


460 


80003 


460 


80074 


460 


80145 


460 


80232 


464 


80353 


460 


80004 


460 


80075 


460 


80146 


460 


80233 


464 


80354 


460 


80005 


460 


80076 


460 


80149 


460 


80234 


464 


80355 


460 


80006 


460 


80079 


460 


80150 


460 


80235 


464 


80356 


460 


80009 


460 


80080 


460 


80151 


460 


80236 


464 


80359 


460 


80010 


460 


80081 


460 


80152 


460 


80237 


464 


80360 


460 



The Development of a Physician Prospective Payment System for Ambulatory Care 



225 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


80361 


460 


80432 


460 


80503 


460 


80634 


460 


8090 


463 


80362 


460 


80433 


460 


80504 


460 


80635 


460 


8091 


463 


80363 


460 


80434 


460 


80505 


460 


80636 


460 


81000 


464 


80364 


460 


80435 


460 


80506 


460 


80637 


460 


81001 


464 


80365 


460 


80436 


460 


80507 


460 


80638 


460 


81002 


464 


80366 


460 


80439 


460 


80508 


460 


80639 


460 


81003 


464 


80369 


460 


80440 


460 


80510 


460 


8064 


460 


81010 


464 


80370 


460 


80441 


460 


80511 


460 


8065 


460 


81011 


464 


80371 


460 


80442 


460 


80512 


460 


80660 


460 


81012 


464 


80372 


460 


80443 


460 


80513 


460 


80661 


460 


81013 


464 


80373 


460 


80444 


460 


80514 


460 


80662 


460 


81100 


464 


80374 


460 . 


80445 


460 


80515 


460 


80669 


460 


81101 


464 


80375 


460 . " 


80446 


460 


80516 


460 


80670 


460 


81102 


464 


80376 


460 


80449 


460 


80517 


460 


80671 


460 


81103 


464 


80379 


460 


80450 


460 


80518 


460 


80672 


460 


81109 


464 


80380 


460 


80451 


460 


8052 


460 


80679 


460 


81110 


464 


80381 


460 


80452 


460 


8033 


460 


8068 


460 


81111 


464 


80382 


460 


80453 


460 


80S4 


460 


8069 


460 


81112 


464 


80383 


460 


80454 


460 


8055 


460 


80700 


463 


81113 


464 


80384 


460 


80455 


460 


8036 


621 


80701 


463 


81119 


464 


80385 


460 


80456 


460 


8057 


621 


80702 


463 


81200 


464 


80386 


460 


80459 


460 


8058 


460 


80703 


463 


81201 


464 


80389 


460 


80460 


460 


8059 


460 


80704 


463 


81202 


464 


80390 


460 


80461 


460 


80600 


460 


80705 


463 


81203 


464 


80391 


460 


80462 


460 


80601 


460 


80706 


463 


81209 


464 


80392 


460 


80463 


460 


80602 


460 


80707 


463 


81210 


464 


80393 


460 


80464 


460 


80603 


460 


80708 


463 


81211 


464 


80394 


460 


80465 


460 


80604 


460 


80709 


463 


81212 


464 


80395 


460 


80466 


460 


80605 


460 


80710 


463 


81213 


464 


803% 


460 


80469 


460 


80606 


460 


80711 


463 


81219 


464 


80399 


460 


80470 


460 


80607 


460 


80712 


463 


81220 


464 


80400 


460 


80471 


460 


80608 


460 


80713 


463 


81221 


464 


80401 


460 


80472 


460 


80609 


460 


80714 


463 


81230 


464 


80402 


460 


80473 


460 


80610 


460 


80715 


463 


81231 


464 


80403 


460 


80474 


460 


80611 


460 


80716 


463 


81240 


464 


80404 


460 


80475 


460 


80612 


460 


80717 


463 


81241 


464 


80405 


460 


80476 


460 


80613 


460 


80718 


463 


81242 


464 


80406 


460 


80479 


460 


80614 


460 


80719 


463 


81243 


464 


80409 


460 


80480 


460 


80615 


460 


8072 


463 


81244 


464 


80410 


460 


80481 


460 


80616 


460 


8073 


463 


81249 


464 


80411 


460 


80482 


460 


80617 


460 


8074 


466 


81250 


464 


80412 


460 


80483 


460 


80618 


460 


8075 


464 


81251 


464 


80413 


460 


80484 


460 


80619 


460 


8076 


464 


81252 


464 


80414 


460 


80485 


460 


80620 


460 


8080 


464 


81253 


464 


80415 


460 


80486 


460 


80621 


460 


8081 


464 


81254 


464 


80416 


460 


80489 


460 


80622 


460 


8082 


464 


81259 


464 


80419 


460 


80490 


460 


80623 


460 


8083 


464 


81300 


464 


80420 


460 


80491 


460 


80624 


460 


80841 


464 


81301 


464 


80421 


460 


80492 


460 


80625 


460 


80842 


464 


81302 


464 


80422 


460 


80493 


460 


80626 


460 


80843 


464 


81303 


464 


80423 


460 


80494 


460 


80627 


460 


80849 


464 


81304 


464 


80424 


460 


80495 


460 


80628 


460 


80851 


464 


81305 


464 


80425 


460 


80496 


460 


80629 


460 


80852 


464 


81306 


464 


80426 


460 


80499 


460 


80630 


460 


80853 


464 


81307 


464 


80429 


460 


80500 


460 


80631 


460 


80859 


464 


81308 


464 


80430 


460 


80501 


460 


80632 


460 


8088 


464 


81310 


464 


80431 


460 


80502 


460 


80633 


460 


8089 


464 


81311 


464 


226 


















Final Report 



'"BW 



• 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


81312 


464 


81504 


463 


82301 


464 


83104 


464 


83654 


464 


81313 


464 


81509 


463 


82302 


464 


83109 


464 


83659 


464 


81314 


464 


81510 


463 


82310 


464 


83110 


464 


83660 


464 


81315 


464 


81511 


463 


82311 


464 


83111 


464 


83661 


464 


81316 


464 


81512 


463 


82312 


464 


83112 


464 


83662 


464 


81317 


464 


81513 


463 


82320 


464 


83113 


464 


83663 


464 


81318 


464 


81514 


463 


82321 


464 


83114 


464 


83664 


464 


81320 


464 


81519 


463 


82322 


464 


83119 


464 


83669 


464 


81321 


464 


81600 


463 


82330 


464 


83200 


464 


8370 


464 


81322 


464 


81601 


463 


82331 


464 


83201 


464 


8371 


464 


81323 


464 


81602 


463 


82332 


464 


83202 


464 


83800 


463 


81330 


464 . 


81603 


463 


82380 


464 


83203 


464 


83801 


464 


81331 


464.' 


81610 


463 


82381 


464 


83204 


464 


83802 


464 


81332 


464 


81611 


463 


82382 


464 


83209 


464 


83803 


463 


81333 


464 


81612 


463 


82390 


464 


83210 


464 


83804 


463 


81340 


464 


81613 


463 


82391 


464 


83211 


464 


83805 


463 


81341 


464 


8170 


463 


82392 


464 


83212 


464 


83806 


463 


81342 


464 


8171 


464 


8240 


464 


83213 


464 


83809 


464 


81343 


464 


8180 


464 


8241 


464 


83214 


464 


83810 


464 


81344 


464 


8181 


464 


8242 


464 


83219 


464 


83811 


464 


81350 


464 


8190 


464 


8243 


464 


83300 


464 


83812 


464 


81351 


464 


8191 


464 


8244 


464 


83301 


464 


83813 


464 


81352 


464 


82000 


464 


8245 


464 


83302 


464 


83814 


464 


81353 


464 


82001 


464 


8246 


464 


83303 


464 


83815 


463 


81354 


464 


82002 


464 


8247 


464 


83304 


464 


83816 


463 


81380 


464 


82003 


464 


8248 


464 


83305 


463 


83819 


464 


81381 


464 


82009 


464 


8249 


464 


83309 


464 


83900 


463 


81382 


464 


82010 


464 


8250 


464 


83310 


464 


83901 


463 


81383 


464 


82011 


464 


8251 


464 


83311 


464 


83902 


463 


81390 


464 


82012 


464 


82520 


464 


83312 


464 


83903 


463 


81391 


464 


82013 


464 


82521 


464 


83313 


464 


83904 


463 


81392 


464 


82019 


464 


82522 


464 


83314 


464 


83905 


463 


81393 


464 


82020 


464 


82523 


464 


83315 


464 


83906 


463 


81400 


464 


82021 


464 


82524 


464 


83319 


464 


83907 


463 


81401 


464 


82022 


464 


82525 


464 


83400 


463 


83908 


463 


81402 


464 


82030 


464 


82529 


464 


83401 


463 


83910 


463 


81403 


464 


82031 


464 


82530 


464 


83402 


463 


83911 


463 


81404 


464 


82032 


464 


82531 


464 


83410 


463 


83912 


463 


81405 


464 


8208 


464 


82532 


464 


83411 


463 


83913 


463 


81406 


464 


8209 


464 


82533 


464 


83412 


463 


83914 


463 


81407 


464 


82100 


464 


82534 


464 


83500 


464 


83915 


463 


81408 


464 


82101 


464 


82535 


464 


83501 


464 


83916 


463 


81409 


464 


82110 


464 


82539 


464 


83502 


464 


83917 


463 


81410 


464 


82111 


464 


8260 


463 


83503 


464 


83918 


463 


81411 


464 


82120 


464 


8261 


463 


83510 


464 


83920 


463 


81412 


464 


82121 


464 


8270 


464 


83511 


464 


83921 


463 


81413 


464 


82122 


464 


8271 


464 


83512 


464 


83930 


463 


81414 


464 


82123 


464 


8280 


464 


83513 


464 


83931 


463 


81415 


464 


82129 


464 


8281 


464 


8360 


464 


83940 


463 


81416 


464 


82130 


464 


8290 


463 


8361 


464 


83941 


463 


81417 


464 


82131 


464 


8291 


464 


8362 


464 


83942 


463 


81418 


464 


82132 


464 


8300 


464 


8363 


464 


83949 


463 


81419 


464 


82133 


464 


8301 


464 


8364 


464 


83950 


463 


81500 


464 


82139 


464 


83100 


464 


83650 


464 


83951 


463 


81501 


463 


8220 


464 


83101 


464 


83651 


464 


83952 


463 


81502 


463 


8221 


464 


83102 


464 


83652 


464 


83959 


463 


81503 


463 


82300 


464 


83103 


464 


83653 


464 


83961 


463 



The Development of a Physician Prospective Payment System for Ambulatory Care 



227 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


83969 


463 


8472 


463 


85143 


460 


85214 


460 


85405 


460 


83971 


463 


8473 


463 


85144 


460 


85215 


460 


85406 


460 


83979 


463 


8474 


463 


85145 


460 


85216 


460 


85409 


460 


8398 


464 


8479 


463 


85146 


460 


85219 


460 


85410 


460 


8399 


464 


8480 


464 


85149 


460 


85220 


460 


85411 


460 


8400 


464 


8481 


464 


85150 


460 


85221 


460 


85412 


460 


8401 


464 


8482 


464 


85151 


460 


85222 


460 


85413 


460 


8402 


464 


8483 


463 


85152 


460 


85223 


460 


85414 


460 


8403 


464 


84840 


463 


85153 


460 


85224 


460 


85415 


460 


8404 


464 


84841 


463 


85154 


460 


85225 


460 


85416 


460 


8405 


464 


84842 


463 


85155 


460 


85226 


460 


85419 


460 


8406 


464 . 


84849 


463 


85156 


460 


85229 


460 


8600 


466 


8408 


464 . ■ 


8485 


464 


85159 


460 


85230 


460 


8601 


466 


8409 


464 


8488 


463 


85160 


460 


85231 


460 


8602 


466 


8410 


464 


8489 


464 


85161 


460 


85232 


460 


8603 


466 


8411 


464 


8500 


460 


85162 


460 


85233 


460 


8604 


466 


8412 


464 


8501 


460 


85163 


460 


85234 


460 


8605 


466 


8413 


464 


8502 


460 


85164 


460 


85235 


460 


86100 


466 


8418 


464 


8503 


460 


85165 


460 


85236 


460 


86101 


466 


8419 


464 


8504 


460 


85166 


460 


85239 


460 


86102 


466 


84200 


464 


8505 


460 


85169 


460 


85240 


460 


86103 


466 


84201 


464 


8509 


460 


85170 


460 


85241 


460 


86110 


466 


84202 


464 


85100 


460 


85171 


460 


85242 


460 


86111 


466 


84209 


464 


85101 


460 


85172 


460 


85243 


460 


86112 


466 


84210 


463 


85102 


460 


85173 


460 


85244 


460 


86113 


466 


84211 


463 


85103 


460 


85174 


460 


85245 


460 


86120 


466 


84212 


463 


85104 


460 


85175 


460 


85246 


460 


86121 


466 


84213 


463 


85105 


460 


85176 


460 


85249 


460 


86122 


466 


84219 


464 


85106 


460 


85179 


460 


85250 


460 


86130 


466 


8430 


464 


85109 


460 


85180 


460 


85251 


460 


86131 


466 


8431 


464 


85110 


460 


85181 


460 


85252 


460 


86132 


466 


8438 


464 


85111 


460 


85182 


460 


85253 


460 


8620 


466 


8439 


464 


85112 


460 


85183 


460 


85254 


460 


8621 


466 


8440 


464 


85113 


460 


85184 


460 


85255 


460 


86221 


466 


8441 


464 


85114 


460 


85185 


460 


85256 


460 


86222 


466 


8442 


464 


85115 


460 


85186 


460 


85259 


460 


86229 


466 


8443 


464 


85116 


460 


85189 


460 


85300 


460 


86231 


466 


8448 


464 


85119 


460 


85190 


460 


85301 


460 


86232 


466 


8449 


464 


85120 


460 


85191 


460 


85302 


460 


86239 


466 


84500 


464 


85121 


460 


85192 


460 


85303 


460 


8628 


466 


84501 


464 


85122 


460 


85193 


460 


85304 


460 


8629 


466 


84502 


464 


85123 


460 


85194 


460 


85305 


460 


8630 


466 


84503 


464 


85124 


460 


85195 


460 


85306 


460 


8631 


466 


84509 


464 


85125 


460 


85196 


460 


85309 


460 


86320 


466 


84510 


463 


85126 


460 


85199 


460 


85310 


460 


86321 


466 


84511 


463 


85129 


460 


85200 


460 


85311 


460 


86329 


466 


84512 


463 


85130 


460 


85201 


460 


85312 


460 


86330 


466 


84513 


463 


85131 


460 


85202 


460 


85313 


460 


86331 


466 


84519 


463 


85132 


460 


85203 


460 


85314 


460 


86339 


466 


8460 


463 


85133 


460 


85204 


460 


85315 


460 


86340 


466 


8461 


463 


85134 


460 


85205 


460 


85316 


460 


86341 


466 


8462 


463 


85135 


460 


85206 


460 


85319 


460 


86342 


466 


8463 


463 


85136 


460 


85209 


460 


85400 


460 


86343 


466 


8468 


463 


85139 


460 


85210 


460 


85401 


460 


86344 


466 


8469 


463 


85140 


460 


85211 


460 


85402 


460 


86345 


466 


8470 


464 


85141 


460 


85212 


460 


85403 


460 


86346 


466 


8471 


464 


85142 


460 


85213 


460 


85404 


460 


86349 


466 


228 


















Final Report 



^m 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


86350 


466 


8671 


466 


8730 


462 


8771 


462 


8861 


466 


86351 


466 


8672 


466 


8731 


462 


8780 


462 


8870 


466 


86352 


466 


8673 


466 


87320 


462 


8781 


462 


8871 


466 


86353 


466 


8674 


466 


87321 


462 


8782 


462 


8872 


466 


86354 


466 


8675 


466 


87322 


462 


8783 


462 


8873 


466 


86355 


466 


8676 


466 


87323 


462 


8784 


462 


8874 


466 


86356 


466 


8677 


466 


87329 


462 


8785 


462 


8875 


466 


86359 


466 


8678 


466 


87330 


462 


8786 


462 


8876 


466 


86380 


466 


8679 


466 


87331 


462 


8787 


462 


8877 


466 


86381 


466 


86800 


466 


87332 


462 


8788 


462 


8900 


462 


86382 


466 


86801 


466 


87333 


462 


8789 


462 


8901 


462 


86383 


466 


86802 


466 


87339 


462 


8790 


462 


8902 


462 


86384 


466 . " 


86803 


466 


87340 


462 


8791 


462 


8910 


462 


86385 


466 


86804 


466 


87341 


462 


8792 


462 


8911 


462 


86389 


466 


86809 


466 


87342 


462 


8793 


462 


8912 


462 


86390 


466 


86810 


466 


87343 


462 


8794 


462 


8920 


462 


86391 


466 


86811 


466 


87344 


462 


8795 


462 


8921 


462 


86392 


466 


86812 


466 


87349 


462 


8796 


462 


8922 


462 


86393 


466 


86813 


466 


87350 


462 


8797 


462 


8930 


462 


86394 


466 


86814 


466 


87351 


462 


8798 


461 


8931 


462 


86395 


466 


86819 


466 


87352 


462 


8799 


461 


8932 


462 


86399 


466 


8690 


466 


87353 


462 


88000 


462 


8940 


462 


86400 


466 


8691 


466 


87354 


462 


88001 


462 


8941 


462 


86401 


466 


8700 


462 


87359 


462 


88002 


462 


8942 


462 


86402 


466 


8701 


466 


87360 


462 


88003 


462 


8950 


466 


86403 


466 


8702 


466 


87361 


462 


88009 


462 


8951 


466 


86404 


466 


8703 


466 


87362 


462 


88010 


462 


8960 


466 


86405 


466 


8704 


466 


87363 


541 


88011 


462 


8961 


466 


86409 


466 


8708 


466 


87364 


462 


88012 


462 


8962 


466 


86410 


466 


8709 


466 


87365 


462 


88013 


462 


8963 


466 


86411 


466 


8710 


466 


87369 


462 


88019 


462 


8970 


466 


86412 


466 


8711 


466 


87370 


462 


88020 


462 


8971 


466 


86413 


466 


8712 


466 


87371 


462 


88021 


462 


8972 


466 


86414 


466 


8713 


466 


87372 


462 


88022 


462 


8973 


466 


86415 


466 


8714 


466 


87373 


541 


88023 


462 


8974 


466 


86419 


466 


8715 


466 


87374 


462 


88029 


462 


8975 


466 


86500 


466 


8716 


466 


87375 


462 


88100 


462 


8976 


466 


86501 


466 


8717 


466 


87379 


462 


88101 


462 


8977 


466 


86502 


466 


8719 


466 


8738 


462 


88102 


462 


90000 


466 


86503 


466 


87200 


462 


8739 


462 


88110 


462 


90001 


466 


86504 


466 


87201 


462 


87400 


462 


88111 


462 


90002 


466 


86509 


466 


87202 


462 


87401 


462 


88112 


462 


90003 


466 


86510 


466 


87210 


462 


87402 


462 


88120 


462 


9001 


466 


86511 


466 


87211 


462 


87410 


462 


88121 


462 


90081 


466 


86512 


466 


87212 


462 


87411 


462 


88122 


462 


90082 


466 


86513 


466 


87261 


462 


87412 


462 


8820 


462 


90089 


466 


86514 


466 


87262 


462 


8742 


462 


8821 


462 


9009 


466 


86519 


466 


87263 


462 


8743 


462 


8822 


462 


9010 


466 


86600 


466 


87264 


462 


8744 


462 


8830 


462 


9011 


466 


86601 


466 


87269 


462 


8745 


462 


8831 


462 


9012 


466 


86602 


466 


87271 


462 


8748 


462 


8832 


462 


9013 


466 


86603 


466 


87272 


462 


8749 


462 


8840 


462 


90140 


466 


86610 


466 


87273 


462 


8750 


462 


8841 


462 


90141 


466 


86611 


466 


87274 


462 


8751 


462 


8842 


462 


90142 


466 


86612 


466 


87279 


462 


8760 


462 


8850 


466 


90181 


466 


86613 


466 


8728 


462 


8761 


462 


8851 


466 


90182 


466 


8670 


466 


8729 


462 


8770 


462 


8860 


466 


90183 


466 



The Development of a Physician Prospective Payment System for Ambulatory Care 



229 



APPENDIX F 


















DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


90189 


466 


90453 


466 


9109 


462 


9166 


462 


92420 


461 


9019 


466 


90454 


466 


9110 


461 


9167 


462 


92421 


461 


9020 


466 


9046 


466 


9111 


461 


9168 


462 


9243 


461 


90210 


466 


9047 


466 


9112 


462 


9169 


461 


9244 


462 


90211 


466 


9048 


466 


9113 


462 


9170 


461 


9245 


461 


90219 


466 


9049 


466 


9114 


461 


9171 


461 


9248 


462 


90220 


466 


9050 


460 


9115 


461 


9172 


461 


9249 


461 


90221 


466 


9051 


463 


9116 


462 


9173 


461 


925 


466 


90222 


466 


9052 


464 


9117 


462 


9174 


461 


9251 


466 


90223 


466 


9053 


464 


9118 


462 


9175 


461 


9252 


466 


90224 


466 


9054 


464 


9119 


462 


9176 


461 


9260 


466 


90225 


466 


9055 


464 


9120 


461 


9177 


461 


92611 


466 


90226 


466 - 


9056 


464 


9121 


461 


9178 


461 


92612 


466 


90227 


466 


9057 


464 


9122 


462 


9179 


461 


92619 


466 


90229 


466 


9058 


464 


9123 


462 


9180 


534 


9268 


466 


90231 


466 


9059 


462 


9124 


461 


9181 


534 


9269 


466 


90232 


466 


9060 


462 


9125 


461 


9182 


534 


92700 


466 


90233 


466 


9061 


462 


9126 


462 


9189 


534 


92701 


466 


90234 


466 


9062 


462 


9127 


462 


9190 


461 


92702 


466 


90239 


466 


9063 


462 


9128 


462 


9191 


461 


92703 


466 


90240 


466 


9064 


466 


9129 


462 


9192 


461 


92709 


466 


90241 


466 


9065 


465 


9130 


461 


9193 


461 


92710 


466 


90242 


466 


9066 


462 


9131 


461 


9194 


461 


92711 


466 


90249 


466 


9067 


462 


9132 


461 


9195 


461 


92720 


464 


90250 


466 


9068 


462 


9133 


461 


9196 


461 


92721 


464 


90251 


466 


9069 


462 


9134 


461 


9197 


461 


9273 


463 


90252 


466 


9070 


460 


9135 


461 


9198 


461 


9278 


466 


90253 


466 


9071 


466 


9136 


461 


9199 


461 


9279 


466 


90254 


466 


9072 


460 


9137 


461 


920 


462 


92800 


466 


90255 


466 


9073 


466 


9138 


461 


9210 


462 


92801 


466 


90256 


466 


9074 


466 


9139 


461 


9211 


462 


92810 


466 


90259 


466 


9075 


466 


9140 


461 


9212 


462 


92811 


466 


90281 


466 


9079 


466 


9141 


461 


9213 


462 


92820 


464 


90282 


466 


9080 


466 


9142 


461 


9219 


534 


92821 


464 


90287 


466 


9081 


466 


9143 


461 


9220 


462 


9283 


463 


90289 


466 


9082 


466 


9144 


461 


9221 


462 


9288 


466 


9029 


466 


9083 


466 


9145 


461 


9222 


462 


9289 


466 


90300 


466 


9084 


466 


9146 


461 


9223 


462 


9290 


466 


90301 


466 


9085 


466 


9147 


461 


9224 


462 


9299 


466 


90302 


466 


9086 


462 


9148 


461 


9228 


462 


9300 


534 


9031 


466 


9089 


462 


9149 


461 


9229 


462 


9301 


466 


9032 


466 


9090 


451 


9150 


461 


92300 


462 


9302 


466 


9033 


466 


9091 


451 


9151 


461 


92301 


462 


9308 


534 


9034 


466 


9092 


466 


9152 


461 


92302 


462 


9309 


534 


9035 


466 


9093 


705 


9153 


461 


92303 


462 


931 


466 


9038 


466 


9094 


466 


9154 


461 


92309 


462 


932 


466 


9039 


466 


9095 


705 


9155 


461 


92310 


461 


9330 


466 


9040 


466 


9099 


466 


9156 


461 


92311 


461 


9331 


466 


9041 


466 


9100 


461 


9157 


461 


92320 


461 


9340 


466 


9042 


466 


9101 


461 


9158 


461 


92321 


461 


9341 


466 


9043 


466 


9102 


462 


9159 


461 


9233 


461 


9348 


466 


90440 


466 


9103 


462 


9160 


461 


9238 


462 


9349 


466 


90441 


466 


9104 


461 


9161 


461 


9239 


461 


9350 


466 


90442 


466 


9105 


461 


9162 


462 


92400 


461 


9351 


466 


90450 


466 


9106 


462 


9163 


462 


92401 


462 


9352 


466 


90451 


466 


9107 


462 


9164 


461 


92410 


461 


936 


466 


90452 


466 


9108 


462 


9165 


461 


92411 


461 


937 


466 


230 


















Final Report 



m 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


938 


466 


94144 


465 


94259 


465 


94408 


465 


94513 


465 


9390 


466 


94145 


465 


94300 


465 


94410 


465 


94514 


465 


9391 


681 


94146 


465 


94301 


465 


94411 


465 


94515 


465 


9392 


466 


94147 


465 


94302 


465 


94412 


465 


94516 


465 


9393 


466 


94148 


465 


94303 


465 


94413 


465 


94519 


465 


9399 


466 


94149 


465 


94304 


465 


94414 


465 


94520 


465 


9400 


465 


94150 


465 


94305 


465 


94415 


465 


94521 


465 


9401 


465 


94151 


465 


94306 


465 


94416 


465 


94522 


465 


9402 


465 


94152 


465 


94309 


465 


94417 


465 


94523 


465 


9403 


465 


94153 


465 


94310 


465 


94418 


465 


94524 


465 


9404 


465 


94154 


465 


94311 


465 


94420 


465 


94525 


465 


9405 


465 


94155 


465 


94312 


465 


94421 


465 


94526 


465 


9409 


465 , - 


94156 


465 


94313 


465 


94422 


465 


94529 


465 


94100 


465 


94157 


465 


94314 


465 


94423 


465 


94530 


465 


94101 


465 


94158 


465 


94315 


465 


94424 


465 


94531 


465 


94102 


465 


94159 


465 


94316 


465 


94425 


465 


94532 


465 


94103 


465 


94200 


465 


94319 


465 


94426 


465 


94533 


465 


94104 


465 


94201 


465 


94320 


465 


94427 


465 


94534 


465 


94105 


465 


94202 


465 


94321 


465 


94428 


465 


94535 


465 


94106 


465 


94203 


465 


94322 


465 


94430 


465 


94536 


465 


94107 


465 


94204 


465 


94323 


465 


94431 


465 


94539 


465 


94108 


465 


94205 


465 


94324 


465 


94432 


465 


94540 


465 


94109 


465 


94209 


465 


94325 


465 


94433 


465 


94541 


465 


94110 


465 


94210 


465 


94326 


465 


94434 


465 


94542 


465 


94111 


465 


94211 


465 


94329 


465 


94435 


465 


94543 


465 


94112 


465 


94212 


465 


94330 


465 


94436 


465 • 


94544 


465 


94113 


465 


94213 


465 


94331 


465 


94437 


465 


94545 


465 


94114 


465 


94214 


465 


94332 


465 


94438 


465 


94546 


465 


94115 


465 


94215 


465 


94333 


465 


94440 


465 


94549 


465 


94116 


465 


94219 


465 


94334 


465 


94441 


465 


94550 


465 


94117 


465 


94220 


465 


94335 


465 


94442 


465 


94551 


465 


94118 


465 


94221 


465 


94336 


465 


94443 


465 


94552 


465 


94119 


465 


94222 


465 


94339 


465 


94444 


465 


94553 


465 


94120 


465 


94223 


465 


94340 


465 


94445 


465 


94554 


465 


94121 


465 


94224 


465 


94341 


465 


94446 


465 


94555 


465 


94122 


465 


94225 


465 


94342 


465 


94447 


465 


94556 


465 


94123 


465 


94229 


465 


94343 


465 


94448 


465 


94559 


465 


94124 


465 


94230 


465 


94344 


465 


94450 


465 


9460 


465 


94125 


465 


94231 


465 


94345 


465 


94451 


465 


9461 


46S 


94126 


465 


94232 


465 


94346 


465 


94452 


465 


9462 


465 


94127 


465 


94233 


465 


94349 


465 


94453 


465 


9463 


465 


94128 


465 


94234 


465 


94350 


465 


94454 


465 


9464 


465 


94129 


465 


94235 


465 


94351 


465 


94455 


465 


9465 


465 


94130 


465 


94239 


465 


94352 


465 


94456 


465 


9470 


465 


94131 


465 


94240 


465 


94353 


465 


94457 


465 


9471 


465 


94132 


465 


94241 


465 


94354 


465 


94458 


465 


9472 


465 


94133 


465 


94242 


465 


94355 


465 


94500 


465 


9473 


465 


94134 


465 


94243 


465 


94356 


465 


94501 


465 


9474 


465 


94135 


465 


94244 


465 


94359 


465 


94502 


465 


9478 


465 


94136 


465 


94245 


465 


94400 


465 


94503 


465 


9479 


465 


94137 


465 


94249 


465 


94401 


465 


94504 


465 


94800 


465 


94138 


465 


94250 


465 


94402 


465 


94505 


465 


94810 


465 


94139 


465 


94251 


465 


94403 


465 


94506 


465 


94811 


465 


94140 


465 


94252 


465 


94404 


465 


94509 


465 


94820 


465 


94141 


465 


94253 


465 


94405 


465 


94510 


465 


94821 


465 


94142 


465 


94254 


465 


94406 


465 


94511 


465 


94822 


465 


94143 


465 


94255 


465 


94407 


465 


94512 


465 


94830 


465 



The Development of a Physician Prospective Payment System for Ambulatory Care 



231 



APPENDIX F 


DX 


PCG 


DX 


PCG 


0X 


PCG 


DX 


PCG 


DX 


PCG 


94831 


465 


9503 


460 


9558 


466 


9624 


451 


9689 


451 


94832 


465 


9509 


460 


9559 


466 


%25 


451 


9690 


451 


94833 


465 


9510 


466 


9560 


466 


9626 


451 


9691 


451 


94840 


465 


9511 


466 


9561 


466 


9627 


451 


9692 


451 


94841 


465 


9512 


466 


9562 


466 


9628 


451 


%93 


451 


94842 


465 


9513 


466 


9563 


466 


9629 


451 


9694 


451 


94843 


465 


9514 


466 


9564 


466 


9630 


451 


9695 


451 


94844 


465 


9515 


466 


9565 


466 


9631 


451 


9696 


451 


94850 


465 


9516 


466 


9568 


466 


9632 


451 


9697 


451 


94851 


465 


9517 


466 


9569 


466 


9633 


451 


9698 


451 


94852 


465 


9518 


466 


9570 


466 


9634 


451 


9699 


451 


94853 


465 


9519 


466 


9571 


466 


9635 


451 


9700 


451 


94854 


465 / 


95200 


460 


9578 


466 


%38 


451 


9701 


451 


94855 


465 


95201 


460 


9579 


466 


9639 


451 


9708 


451 


94860 


465 


95202 


460 


9580 


466 


9640 


451 


9709 


451 


94861 


465 


95203 


460 


9581 


466 


9641 


451 


9710 


451 


94862 


465 


95204 


460 


9582 


466 


9642 


451 


9711 


451 


94863 


465 


95205 


460 


9583 


501 


9643 


451 


9712 


451 


94864 


465 


95206 


460 


9584 


466 


9644 


451 


9713 


451 


94865 


465 


95207 


460 


9585 


466 


9645 


451 


9719 


451 


94866 


465 


95208 


460 


9586 


465 


9646 


451 


9720 


451 


94870 


465 


95209 


460 


9587 


705 


9647 


451 


9721 


451 


94871 


465 


95210 


460 


9588 


705 


9648 


451 


9722 


451 


94872 


465 


95211 


460 


9590 


705 


9649 


451 


9723 


451 


94873 


465 


95212 


460 


9591 


705 


96500 


451 


9724 


451 


94874 


465 


95213 


460 


9592 


705 


96501 


451 


9725 


451 


94875 


465 


95214 


460 


9593 


705 


96502 


451 


9726 


451 


94876 


465 


95215 


460 


9594 


705 


96509 


451 


9727 


451 


94877 


465 


95216 


460 


9595 


705 


%51 


451 


9728 


451 


94880 


465 


95217 


460 


9596 


705 


9654 


451 


9729 


451 


94881 


465 


95218 


460 


9597 


705 


%55 


451 


9730 


451 


94882 


465 


95219 


460 


9598 


705 


9656 


451 


9731 


451 


94883 


465 


9522 


460 


9599 


705 


9657 


451 


9732 


451 


94884 


465 


9523 


460 


9600 


451 


9658 


451 


9733 


451 


94885 


465 


9524 


460 


9601 


451 


9659 


451 


9734 


451 


94886 


465 


9528 


460 


9602 


451 


9660 


451 


9735 


451 


94887 


465 


9529 


460 


9603 


451 


%61 


451 


9736 


451 


94888 


465 


9530 


460 


9604 


451 


9662 


451 


9738 


451 


94890 


465 


9531 


460 


9605 


451 


9663 


451 


9739 


451 


94891 


465 


9532 


460 


9606 


451 


9664 


451 


9740 


451 


94892 


465 


9533 


460 


9607 


451 


9670 


451 


9741 


451 


94893 


465 


9534 


466 


9608 


451 


9671 


451 


9742 


451 


94894 


465 


9535 


460 


9609 


451 


9672 


451 


9743 


451 


94895 


465 


9538 


460 


9610 


451 


9673 


451 


9744 


451 


94896 


465 


9539 


460 


9611 


451 


9674 


451 


9745 


451 


94897 


465 


9540 


466 


9612 


451 


9675 


451 


9746 


451 


94898 


465 


9541 


466 


9613 


451 


9676 


451 


9747 


451 


94899 


465 


9548 


466 


9614 


451 


9678 


451 


9750 


451 


9490 


465 


9549 


466 


9615 


451 


9679 


451 


9751 


451 


9491 


465 


9550 


466 


9616 


451 


9680 


451 


9752 


451 


9492 


465 


9551 


466 


9617 


451 


9681 


451 


9753 


451 


9493 


465 


9552 


466 


9618 


451 


9682 


451 


9754 


451 


9494 


465 


9553 


466 


9619 


451 


9683 


451 


9755 


451 


9495 


465 


9554 


466 


9620 


451 


9684 


451 


9756 


451 


9500 


460 


9555 


466 


9621 


451 


9685 


451 


9757 


451 


9501 


460 


9556 


466 


9622 


451 


9686 


451 


9758 


451 


9502 


460 


9557 


466 


9623 


451 


9687 


451 


9760 


451 


232 


















Final Report 



*^i- 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


9761 


451 


9852 


451 


9929 


466 


99663 


515 


9988 


705 


9762 


451 


9853 


451 


9930 


544 


99664 


665 


99881 


F 


9763 


451 


9854 


451 


9931 


544 


99665 


665 


99882 


534 


9764 


451 


9855 


451 


9932 


466 


99666 


628 


99889 


705 


9765 


451 


9856 


451 


9933 


466 


99667 


628 


9989 


705 


9766 


451 


9858 


451 


9934 


466 


99669 


466 


9990 


501 


9767 


451 


9859 


451 


9938 


466 


99670 


466 


9991 


564 


9768 


451 


986 


451 


9939 


466 


99671 


576 


9992 


575 


9769 


451 


9870 


451 


9940 


465 


99672 


576 


9993 


501 


9770 


451 


9871 


451 


9941 


466 


99673 


576 


9994 


611 


9771 


451 


9872 


451 


9942 


466 


99674 


576 


9995 


694 


9772 


451 . 


9873 


451 


9943 


466 


99675 


515 


9996 


694 


9773 


451 .■ 


9874 


451 


9944 


466 


99676 


G 


9997 


694 


9774 


451 


9875 


451 


9945 


466 


99677 


628 


9998 


694 


9778 


451 


9876 


451 


9946 


705 


99678 


628 


9999 


705 


9779 


451 


9877 


451 


9947 


466 


99679 


466 


E8000 


997 


9780 


451 


9878 


451 


9948 


466 


99680 


466 


E8001 


997 


9781 


451 


9879 


451 


9949 


466 


99681 


665 


E8002 


997 


9782 


451 


9880 


451 


9950 


611 


99682 


593 


E80O3 


997 


9783 


451 


9881 


451 


9951 


466 


99683 


576 


E80O8 


997 


9784 


451 


9882 


451 


9952 


451 


99684 


564 


E8009 


997 


9785 


451 


9888 


451 


9953 


635 


99685 


693 


E8010 


997 


9786 


451 


9889 


451 


9954 


466 


99686 


593 


E80n 


997 


9788 


451 


9890 


451 


9955 


L 


99689 


466 


E8012 


997 


9789 


451 


9891 


451 


99560 


611 


99690 


628 


E8013 


997 


9790 


451 


9892 


451 


99561 


611 


99691 


628 


E8018 


997 


9791 


451 


9893 


451 


99562 


611 


99692 


628 


E8019 


997 


9792 


451 


9894 


451 


99563 


611 


99693 


628 


E8020 


997 


9793 


451 


9895 


451 


99564 


611 


99694 


628 


E8021 


997 


9794 


451 


9896 


451 


99565 


611 


99695 


628 


E8022 


997 


9795 


451 


9897 


451 


99566 


611 


99696 


628 


E8023 


997 


9796 


451 


9898 


451 


99567 


611 


99699 


628 


E8028 


997 


9797 


451 


98981 


451 


99568 


611 


9970 


515 


E8029 


997 


9799 


451 


98982 


451 


99569 


611 


99700 


515 


E8030 


997 


9800 


451 


98983 


451 


99581 


L 


99701 


515 


E8031 


997 


9801 


451 


98984 


451 


99589 


515 


99702 


511 


E8032 


997 


9802 


451 


98989 


451 


99600 


576 


99709 


515 


E8033 


997 


9803 


451 


9899 


451 


99601 


576 


9971 


576 


E8038 


997 


9808 


451 


990 


466 


99602 


576 


9972 


576 


E8039 


997 


9809 


451 


9910 


466 


99603 


576 


9973 


564 


E8040 


997 


981 


451 


9911 


466 


99604 


576 


9974 


596 


E8041 


997 


9820 


451 


9912 


466 


99609 


576 


9975 


665 


E8042 


997 


9821 


451 


9913 


466 


9961 


576 


99760 


628 


E8043 


997 


9822 


451 


9914 


466 


9962 


515 


99761 


622 


E8048 


997 


9823 


451 


9915 


466 


99630 


G 


99762 


628 


E8049 


997 


9824 


451 


9916 


466 


99631 


G 


99769 


628 


E8050 


997 


9828 


451 


9918 


466 


99632 


681 


9979 


466 


E8051 


997 


9830 


451 


9919 


466 


99639 


G 


99791 


575 


E8052 


997 


9831 


451 


9920 


466 


9964 


628 


99799 


705 


E8053 


997 


9832 


451 


9921 


466 


99651 


534 


9980 


466 


E8058 


997 


9839 


451 


9922 


466 


99652 


466 


9981 


466 


E8059 


997 


9840 


451 


9923 


466 


99653 


534 


9982 


466 


E8060 


997 


9841 


451 


9924 


466 


99654 


634 


9983 


705 


E8061 


997 


9848 


451 


9925 


466 


99659 


466 


9984 


466 


E8062 


997 


9849 


451 


9926 


466 


99660 


466 


9985 


501 


E8063 


997 


9850 


451 


9927 


466 


99661 


576 


9986 


466 


E8068 


997 


9851 


451 


9928 


466 


99662 


576 


9987 


466 


E8069 


997 



The Development of a Physician Prospective Payment System for Ambulatory Care 



233 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


E8070 


997 


£8151 


997 


£8208 


997 


£8268 


997 


£8344 


997 


E8071 


997 


£8152 


997 


£8209 


997 


£8269 


997 


£8345 


997 


E8072 


997 


£8153 


997 


£8210 


997 


£8270 


997 


£8346 


997 


E8073 


997 


£8154 


997 


£8211 


997 


£8272 


997 


£8348 


997 


E8078 


997 


£8155 


997 


£8212 


997 


£8273 


997 


£8349 


997 


E8079 


997 


£8156 


997 


£8213 


997 


£8274 


997 


£8350 


997 


E8100 


997 


£8157 


997 


£8214 


997 


£8278 


997 


£8351 


997 


£8101 


997 


£8158 


997 


£8215 


997 


£8279 


997 


£8352 


997 


E8102 


997 


£8159 


997 


£8216 


997 


£8280 


997 


£8353 


997 


E8103 


997 


£8160 


997 


£8217 


997 


£8282 


997 


£8354 


997 


E8104 


997 


£8161 


997 


£8218 


997 


£8284 


997 


£8355 


997 


E8105 


997 . 


£8162 


997 


£8219 


997 


£8288 


997 


E8356 


997 


E8106 


997 . ■ 


E8163 


997 


£8220 


997 


£8289 


997 


£8358 


997 


E8107 


997 


£8164 


997 


£8221 


997 


£8290 


997 


£8359 


997 


E8108 


997 


£8165 


997 


E8222 


997 


£8294 


997 


£8360 


997 


E8109 


997 


£8166 


997 


£8223 


997 


£8298 


997 


£8361 


997 


E8110 


997 


£8167 


997 


£8224 


997 


£8299 


997 


£8362 


997 


E8111 


997 


£8168 


997 


£8225 


997 


£8300 


997 


£8363 


997 


E8112 


997 


£8169 


997 


£8226 


997 


£8301 


997 


£8364 


997 


E8I13 


997 


£8170 


997 


£8227 


997 


£8302 


997 


£8365 


997 


£8114 


997 


£8171 


997 


£8228 


997 


E8303 


997 


£8366 


997 


£8115 


997 


£8172 


997 


£8229 


997 


£8304 


997 


E8368 


997 


E8116 


997 


£8173 


997 


£8230 


997 


£8305 


997 


£8369 


997 


£81 17 


997 


£8174 


997 


£8231 


997 


£8306 


997 


£8370 


997 


£8118 


997 


£8175 


997 


£8232 


997 


E8308 


997 


£8371 


997 


E8119 


997 


£8176 


997 


£8233 


997 


E8309 


997 • 


£8372 


997 


E8120 


997 


£8177 


997 


£8234 


997 


£8310 


997 


£8373 


997 


£8121 


997 


£8178 


997 


£8235 


997 


£8311 


997 


E8374 


997 


£8122 


997 


£8179 


997 


£8236 


997 


£8312 


997 


£8375 


997 


£8123 


997 


£8180 


997 


£8237 


997 


£8313 


997 


£8376 


997 


£8124 


997 


£8181 


997 


£8238 


997 


£8314 


997 


£8378 


997 


£8125 


997 


£8182 


997 


£8239 


997 


£8315 


997 


£8379 


997 


£8126 


997 


£8183 


997 


£8240 


997 


£8316 


997 


£8380 


997 


£8127 


997 


£8184 


997 


£8241 


997 


£8318 


997 


£8381 


997 


E8128 


997 


£8185 


997 


£8242 


997 


E8319 


997 


£8382 


997 


£8129 


997 


£8186 


997 


£8243 


997 


£8320 


997 


£8383 


997 


£8130 


997 


£8187 


997 


£8244 


997 


£8321 


997 


£8384 


997 


E8131 


997 


£8188 


997 


£8245 


997 


£8322 


997 


£8385 


997 


£8132 


997 


£8189 


997 


£8246 


997 


£8323 


997 


£8386 


997 


£8133 


997 


£8190 


997 


£8247 


997 


£8324 


997 


£8388 


997 


£8134 


997 


£8191 


997 


£8248 


997 


£8325 


997 


£8389 


997 


£8135 


997 


£8192 


997 


£8249 


997 


£8326 


997 


£8400 


997 


£8136 


997 


£8193 


997 


£8250 


997 


£8328 


997 


£8401 


997 


£8137 


997 


£8194 


997 


£8251 


997 


£8329 


997 


£8402 


997 


E8138 


997 


£8195 


997 


£8252 


997 


£8330 


997 


£8403 


997 


£8139 


997 


£8196 


997 


£8253 


997 


£8331 


997 


£8404 


997 


£8140 


997 


£8197 


997 


£8254 


997 


£8332 


997 


£8405 


997 


£8141 


997 


£8198 


997 


E8255 


997 


£8333 


997 


£8406 


997 


£8142 


997 


£8199 


997 


£8256 


997 


E8334 


997 


£8407 


997 


£81 43 


997 


£8200 


997 


£8257 


997 


£8335 


997 


£8408 


997 


E8I44 


997 


£8201 


997 


£8258 


997 


£8336 


997 


£8409 


997 


£8145 


997 


£8202 


997 


£8259 


997 


£8338 


997 


£8410 


997 


£8146 


997 


£8203 


997 


£8260 


997 


£8339 


997 


£8411 


997 


E8147 


997 


£8204 


997 


£8261 


997 


E8340 


997 


£8412 


997 


£8148 


997 


£8205 


997 


£8262 


997 


£8341 


997 


£8413 


997 


£8149 


997 


£8206 


997 


£8263 


997 


£8342 


997 


£8414 


997 


£8150 


997 


£8207 


997 


£8264 


997 


E8343 


997 


£8415 


997 


234 


















Final Report 



*w 















1 


Map of ICD-9-CM Diagnosis 


Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


E8416 


997 


E8522 


997 


E8629 


997 


E8709 


997 


E8788 


997 


E84I7 


997 


E8523 


997 


E8630 


997 


E8710 


997 


E8789 


997 


E8418 


997 


E8524 


997 


E8631 


997 


E87I1 


997 


E8790 


997 


E8419 


997 


E8525 


997 


E8632 


997 


E8712 


997 


E8791 


997 


E8426 


997 


E8528 


997 


E8633 


997 


E8713 


997 


E8792 


997 


E8427 


997 


E8529 


997 


E8634 


997 


E8714 


997 


E8793 


997 


E8428 


997 


E8530 


997 


E8635 


997 


E8715 


997 


E8794 


997 


E8429 


997 


E8531 


997 


E8636 


997 


E8716 


997 


E8795 


997 


E8430 


997 


E8532 


997 


E8637 


997 


E8717 


997 


E8796 


997 


E8431 


997 


E8538 


997 


E8638 


997 


E8718 


997 


E8797 


997 


E8432 


997 


E8539 


997 


E8639 


997 


E87I9 


997 


E8798 


997 


E8433 


997 . 


E8540 


997 


E8640 


997 


E8720 


997 


E8799 


997 


E8434 


997 .' 


E8541 


997 


E8641 


997 


E8721 


997 


E8800 


997 


E8435 


997 


E8542 


997 


E8642 


997 


E8722 


997 


E8801 


997 


E8436 


997 


E8543 


997 


E8643 


997 


E8723 


997 


E8809 


997 


E8437 


997 


E8548 


997 


E8644 


997 


E8724 


997 


E8810 


997 


E8438 


997 


E8550 


997 


E8650 


997 


E8725 


997 


E8811 


997 


E8439 


997 


E855I 


997 


E8651 


997 


E8726 


997 


E882 


997 


E8440 


997 


E8552 


997 


E8652 


997 


E8728 


997 


E8830 


997 


E844I 


997 


E8553 


997 


E8653 


997 


E8729 


997 


E8831 


997 


E8442 


997 


E8554 


997 


E8654 


997 


E8730 


997 


E8832 


997 


E8443 


997 


E8555 


997 


E8655 


997 


E8731 


997 


E8839 


997 


E8444 


997 


E8556 


997 


E8658 


997 


E8732 


997 


E8840 


997 


E8445 


997 


E8558 


997 


E8659 


997 


E8733 


997 


E8841 


997 


E8446 


997 


E8559 


997 


E8660 


997 


E8734 


997 


E8842 


997 


E8447 


997 


E856 


997 


E8661 


997 


E8735 


997 


E8843 


997 


E8448 


997 


E857 


997 


E8662 


997 


E8736 


997 


E8844 


997 


E8449 


997 


E8580 


997 


E8663 


997 


E8738 


997 


E8845 


997 


E8450 


997 


E858I 


997 


E8664 


997 


E8739 


997 


E8846 


997 


E8458 


997 


E8582 


997 


E8665 


997 


E8740 


997 


E8849 


997 


E8459 


997 


E8583 


997 


E8666 


997 


E8741 


997 


E885 


997 


E846 


997 


E8584 


997 


E8667 


997 


E8742 


997 


E8860 


997 


E847 


997 


E8585 


997 


E8668 


997 


E8743 


997 


E8869 


997 


E848 


997 


E8586 


997 


E8669 


997 


E8744 


997 


E887 


997 


E8490 


997 


E8587 


997 


E867 


997 


E8745 


997 


E888 


997 


E8491 


997 


E8588 


997 


E8680 


997 


E8748 


997 


E8900 


997 


E8492 


997 


E8589 


997 


E868I 


997 


E8749 


997 


E8901 


997 


E8493 


997 


E8600 


997 


E8682 


997 


E8750 


997 


E8902 


997 


E8494 


997 


E8601 


997 


E8683 


997 


E8751 


997 


E8903 


997 


E8495 


997 


E8602 


997 


E8688 


997 


E8752 


997 


E8908 


997 


E8496 


997 


E8603 


997 


E8689 


997 


E8758 


997 


E8909 


997 


E8497 


997 


E8604 


997 


E8690 


997 


E8759 


997 


E89I0 


997 


E8498 


997 


E8608 


997 


E8691 


997 


E8760 


997 


E8911 


997 


E8499 


997 


E8609 


997 


E8692 


997 


E8761 


997 


E8912 


997 


E8500 


997 


E8610 


997 


E8693 


997 


E8762 


997 


E89I3 


997 


E8501 


997 


E861I 


997 


E8694 


997 


E8763 


997 


E8918 


997 


E8502 


997 


E8612 


997 


E8698 


997 


E8764 


997 


E8919 


997 


E8503 


997 


E86I3 


997 


E8699 


997 


E8765 


997 


E892 


997 


E8504 


997 


E8614 


997 


E8700 


997 


E8768 


997 


E8930 


997 


E8505 


997 


E8615 


997 


E870I 


997 


E8769 


997 


E8931 


997 


E8506 


997 


E8616 


997 


E8702 


997 


E8780 


997 


E8932 


997 


E8507 


997 


E8619 


997 


E8703 


997 


E8781 


997 


E8938 


997 


E8508 


997 


E8620 


997 


E8704 


997 


E8782 


997 


E8939 


997 


E8509 


997 


E8621 


997 


E8705 


997 


E8783 


997 


E894 


997 


E851 


997 


E8622 


997 


E8706 


997 


E8784 


997 


E895 


997 


E8520 


997 


E8623 


997 


E8707 


997 


E8785 


997 


E896 


997 


E8521 


997 


E8624 


997 


E8708 


997 


E8786 


997 


E897 


997 



The Development of a Physician Prospective Payment System for Ambulatory Care 



235 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


E8980 


997 


E9101 


997 


E9242 


997 


E9327 


997 


E9393 


997 


E8981 


997 


E9102 


997 


E9248 


997 


E9328 


997 


E9394 


997 


E899 


997 


E9103 


997 


E9249 


997 


E9329 


997 


E9395 


997 


E9000 


997 


E9104 


997 


E9250 


997 


E9330 


997 


E9396 


997 


E9001 


997 


E9108 


997 


E9251 


997 


E9331 


997 


E9397 


997 


E9009 


997 


E9109 


997 


E9252 


997 


E9332 


997 


E9398 


997 


E9010 


997 


E911 


997 


E9258 


997 


E9333 


997 


E9399 


997 


E90I1 


997 


E912 


997 


E9259 


997 


E9334 


997 


E9400 


997 


E9018 


997 


E9130 


997 


E9260 


997 


E9335 


997 


E940I 


997 


E9019 


997 


E9131 


997 


E9261 


997 


E9338 


997 


E9408 


997 


E9020 


997 


E9132 


997 


E9262 


997 


E9339 


997 


E9409 


997 


E902I 


997 . 


E9133 


997 


E9263 


997 


E9340 


997 


E9410 


997 


E9022 


997. 


E9I38 


997 


E9264 


997 


E9341 


997 


E9411 


997 


E9028 


997 


E9139 


997 


E9265 


997 


E9342 


997 


E9412 


997 


E9029 


997 


E914 


997 


E9268 


997 


E9343 


997 


E9413 


997 


E903 


997 


E915 


997 


E9269 


997 


E9344 


997 


E94I9 


997 


E9040 


997 


E916 


997 


E927 


997 


E9345 


997 


E9420 


997 


E9041 


997 


E9170 


997 


E9280 


997 


E9346 


997 


E942I 


997 


E9042 


997 


E917I 


997 


E928I 


997 


E9347 


997 


E9422 


997 


E9043 


997 


E9172 


997 


E9282 


997 


E9348 


997 


E9423 


997 


E9049 


997 


E9I79 


997 


E9288 


997 


E9349 


997 


E9424 


997 


E9050 


997 


E918 


997 


E9289 


997 


E9350 


997 


E9425 


997 


E9051 


997 


E9190 


997 


E9290 


997 


E9351 


997 


E9426 


997 


E9052 


997 


E919I 


997 


E9291 


997 


E9352 


997 


E9427 


997 


E9053 


997 


E9192 


997 


E9292 


997 


E9353 


997 


E9428 


997 


E9054 


997 


E9193 


997 


E9293 


997 


E9354 


997 


E9429 


997 


E9055 


997 


E9194 


997 


E9294 


997 


E9355 


997 


E9430 


997 


E9056 


997 


E9195 


997 


E9295 


997 


E9356 


997 


E9431 


997 


E9057 


997 


E9196 


997 


E9298 


997 


E9357 


997 


E9432 


997 


E9058 


997 


E9I97 


997 


E9299 


997 


E9358 


997 


E9433 


997 


E9059 


997 


E9198 


997 


E9300 


997 


E9359 


997 


E9434 


997 


E9060 


997 


E9199 


997 


E9301 


997 


E9360 


997 


E9435 


997 


E9061 


997 


E9200 


997 


E9302 


997 


E936I 


997 


E9436 


997 


E9062 


997 


E9201 


997 


E9303 


997 


E9362 


997 


E9438 


997 


E9063 


997 


E9202 


997 


E9304 


997 


E9363 


997 


E9439 


997 


E9064 


997 


E9203 


997 


E9305 


997 


E9364 


997 


E9440 


997 


E9065 


997 


E9204 


997 


E9306 


997 


E9370 


997 


E9441 


997 


E9068 


997 


E9205 


997 


E9307 


997 


E9371 


997 


E9442 


997 


E9069 


997 


E9208 


997 


E9308 


997 


E9372 


997 


E9443 


997 


E907 


997 


E9209 


997 


E9309 


997 


E9373 


997 


E9444 


997 


E908 


997 


E9210 


997 


E9310 


997 


E9374 


997 


E9445 


997 


E9080 


997 


E9211 


997 


E9311 


997 


E9375 


997 


E9446 


997 


E9081 


997 


E9218 


997 


E9312 


997 


E9376 


997 


E9447 


997 


E9082 


997 


E9219 


997 


E93I3 


997 


E9378 


997 


E9450 


997 


E9083 


997 


E9220 


997 


E9314 


997 


E9379 


997 


E9451 


997 


E9084 


997 


E9221 


997 


E9315 


997 


E9380 


997 


E9452 


997 


E9088 


997 


E9222 


997 


E9316 


997 


E9381 


997 


E9453 


997 


E9089 


997 


E9223 


997 


E9317 


997 


E9382 


997 


E9454 


997 


E909 


997 


E9228 


997 


E9318 


997 


E9383 


997 


E9455 


997 


E9090 


997 


E9229 


997 


E9319 


997 


E9384 


997 


E9456 


997 


E9091 


997 


E9230 


997 


E9320 


997 


E9385 


997 


E9457 


997 


E9092 


997 


E9231 


997 


E9321 


997 


E9386 


997 


E9458 


997 


E9093 


997 


E9232 


997 


E9322 


997 


E9387 


997 


E9460 


997 


E9094 


997 


E9238 


997 


E9323 


997 


E9389 


997 


E9461 


997 


E9098 


997 


E9239 


997 


E9324 


997 


E9390 


997 


E9462 


997 


E9099 


997 


E9240 


997 


E9325 


997 


E9391 


997 


E9463 


997 


E9100 


997 


E9241 


997 


E9326 


997 


E9392 


997 


E9464 


997 


236 
















1 


=inal Report 



Map of ICD-9-CM Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


E9465 


997 


E9555 


997 


E977 


997 


E996 


997 


V060 


705 


E9466 


997 


E9559 


997 


E978 


997 


E9970 


997 


V061 


705 


E9467 


997 


E956 


997 


E9800 


997 


E9971 


997 


V062 


705 


E9468 


997 


E9570 


997 


E9801 


997 


E9972 


997 


V063 


705 


E9469 


997 


E9571 


997 


E9802 


997 


E9978 


997 


V064 


705 


E9470 


997 


E9572 


997 


E9803 


997 


E9979 


997 


V065 


705 


E9471 


997 


E9579 


997 


E9804 


997 


E998 


997 


V066 


705 


E9472 


997 


E9580 


997 


E9805 


997 


£999 


997 


V068 


705 


E9473 


997 


E9581 


997 


E9806 


997 


VOIO 


705 


V069 


705 


E9474 


997 


E9582 


997 


E9807 


997 


von 


705 


V070 


705 


E9478 


997 


E9583 


997 


E9808 


997 


V012 


705 


V071 


705 


E9479 


997 ^ 


E9584 


997 


E9809 


997 


V013 


705 


V072 


705 


E9480 


997 . " 


E9585 


997 


E9810 


997 


V014 


705 


V073 


705 


E9481 


997 


E9586 


997 


E9811 


997 


V015 


705 


V0731 


705 


E9482 


997 


E9587 


997 


E9818 


997 


V016 


705 


V0739 


705 


E9483 


997 


E9588 


997 


E9820 


997 


von 


705 


V074 


705 


E9484 


997 


E9589 


997 


E9821 


997 


V018 


705 


V078 


705 


E9485 


997 


E959 


997 


E9828 


997 


vow 


705 


V079 


705 


E9486 


997 


E9600 


997 


E9829 


997 


V020 


705 


V08 


691 


E9488 


997 


E9601 


997 


E9830 


997 


V021 


705 


V090 


501 


E9489 


997 


E961 


997 


E9831 


997 


V022 


705 


V091 


501 


E9490 


997 


E9620 


997 


E9838 


997 


V023 


705 


V092 


501 


E9491 


997 


E9621 


997 


E9839 


997 


V024 


705 


V093 


501 


E9492 


997 


E9622 


997 


E984 


997 


V025 


705 


V094 


501 


E9493 


997 


E9629 


997 


E9850 


997 


V026 


705 


V0950 


501 


E9494 


997 


E963 


997 


E9851 


997 


V027 


705 


V0951 


501 


E9495 


997 


E964 


997 


E9852 


997 


V028 


705 


V096 


501 


E9496 


997 


E9650 


997 


E9853 


997 


V029 


705 


V0970 


501 


E9497 


997 


E9651 


997 


E9854 


997 


V030 


705 


V0971 


501 


E9499 


997 


E9652 


997 


E9855 


997 


V031 


705 


V0980 


501 


E950O 


997 


E9653 


997 


E986 


997 


V032 


705 


V0981 


501 


£9501 


997 


E9654 


997 


E9870 


997 


V033 


705 


V0990 


501 


E9502 


997 


E9655 


997 


E9871 


997 


V034 


705 


V0991 


501 


E9503 


997 


E9656 


997 


E9872 


997 


V035 


705 


VIOOO 


705 


E9504 


997 


E9657 


997 


E9879 


997 


V036 


705 


VlOOl 


705 


E9505 


997 


E9658 


997 


E9880 


997 


V037 


705 


VI 002 


705 


E9506 


997 


E9659 


997 


E9881 


997 


V038 


705 


V1003 


705 


E9507 


997 


E966 


997 


E9882 


997 


V0381 


705 


VI 004 


705 


E9508 


997 


E9670 


997 


E9883 


997 


V0382 


705 


VI 005 


705 


E9509 


997 


E9671 


997 


E9884 


997 


V0389 


705 


V1006 


705 


E95I0 


997 


E9679 


997 


E9885 


997 


V039 


705 


VI 007 


705 


E9511 


997 


E9680 


997 


E9886 


997 


V040 


705 


V1009 


705 


E9518 


997 


E9681 


997 


E9887 


997 


V041 


705 


VIOII 


705 


E9520 


997 


E9682 


997 


E9888 


997 


V042 


705 


V1012 


705 


E9521 


997 


E9683 


997 


E9889 


997 


V043 


705 


VI 020 


705 


E9528 


997 


E9684 


997 


E989 


997 


V044 


705 


V1021 


705 


E9529 


997 


E9685 


997 


E9900 


997 


V045 


705 


V1022 


705 


E9530 


997 


E9688 


997 


E9909 


997 


V046 


705 


V1029 


705 


E9531 


997 


E9689 


997 


E9910 


997 


V047 


705 


V103 


705 


E9538 


997 


E969 


997 


E9911 


997 


V04« 


705 


VI 040 


705 


E9539 


997 


E970 


997 


E9912 


997 


V050 


705 


V1041 


705 


E954 


997 


E971 


997 


E9913 


997 


V051 


705 


VI 042 


705 


E9550 


997 


E972 


997 


E9919 


997 


V052 


705 


V1043 


705 


E9551 


997 


E973 


997 


E992 


997 


V053 


705 


VI 044 


705 


E9552 


997 


E974 


997 


£993 


997 


V054 


705 


V1045 


705 


E9553 


997 


E975 


997 


E994 


997 


V058 


705 


VI 046 


705 


E9554 


997 


E976 


997 


E995 


997 


V059 


705 


VI 047 


705 



The Development of a Physician Prospective Payment System for Ambulatory Care 



237 



APPENDIX F 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


V1049 


705 


VI34 


705 


V187 


705 


V272 


998 


V401 


B 


VI 050 


705 


VI35 


705 


VI88 


705 


V273 


998 


V402 


B 


V1051 


705 


VI36 


705 


VI90 


705 


V274 


998 


V403 


B 


VI 052 


705 


VI37 


705 


VI9I 


705 


V275 


998 


V409 


B 


VI 059 


705 


V138 


705 


VI92 


705 


V276 


998 


V410 


705 


V1060 


705 


VI39 


705 


VI93 


705 


V277 


998 


V41I 


705 


V1061 


705 


VI40 


705 


VI94 


705 


V279 


998 


V412 


705 


V1062 


705 


VI4I 


705 


VI95 


705 


V280 


491 


V413 


705 


V1063 


705 


VI42 


705 


VI% 


705 


V281 


491 


V4I4 


705 


V1069 


705 


V143 


705 


V197 


705 


V282 


491 


V415 


705 


V1071 


705 


VI44 


705 


VI98 


705 


V283 


491 


V416 


705 


VI 072 


705 . 


VI45 


705 


V200 


702 


V284 


491 


V417 


B 


VI 079 


705 . ■" 


VI46 


705 


V201 


702 


V285 


491 


V418 


B 


V1081 


705 


VI47 


705 


V202 


702 


V288 


491 


V419 


B 


VI 082 


705 


VI48 


705 


V2I0 


702 


V289 


491 


V420 


665 


VI 083 


705 


VI49 


705 


V2II 


702 


V290 


705 


V421 


576 


VI 084 


705 


VI50 


705 


V2I2 


702 


V29I 


705 


V422 


575 


V1085 


705 


V15I 


705 


V2I8 


702 


V292 


705 


V423 


635 


VI 086 


705 


VI52 


705 


V2I9 


702 


V298 


705 


V424 


628 


VI 087 


705 


V153 


705 


V220 


491 


V299 


705 


V425 


534 


V1088 


705 


VI54 


705 


V221 


491 


V3000 


481 


V426 


564 


VI 089 


705 


VI55 


705 


V222 


998 


V3001 


481 


V427 


597 


V109 


705 


V156 


705 


V230 


491 


V30I 


481 


V428 


597 


vno 


705 


VI57 


705 


V23I 


491 


V302 


481 


V429 


705 


vin 


705 


VI58I 


705 


V232 


491 


V3I00 


481 


V430 


534 


vn2 


705 


VI 582 


705 


V233 


491 


V310I 


481 


V431 


704 


VI 13 


705 


VI 584 


705 


V234 


491 


V311 


481 


V432 


575 


VI 18 


705 


VI585 


705 


V235 


491 


V3I2 


481 


V433 


575 


V119 


705 


VI 586 


705 


V237 


492 


V3200 


481 


V434 


575 


V120 


705 


VI 589 


705 


V238 


491 


V320I 


481 


V435 


665 


VI 200 


705 


VI59 


705 


V239 


491 


V321 


481 


V436 


622 


V1201 


705 


V160 


705 


V240 


493 


V322 


481 


V4360 


704 


V1202 


705 


VI61 


705 


V241 


493 


V3300 


481 


V4361 


704 


V1203 


705 


V162 


705 


V242 


493 


V330I 


481 


V4362 


704 


V1209 


705 


V163 


705 


V2501 


703 


V331 


481 


V4363 


704 


V121 


705 


V164 


705 


V2502 


703 


V332 


481 


V4364 


704 


V122 


705 


V165 


705 


V2509 


703 


V3400 


481 


V4365 


704 


V123 


705 


VI66 


705 


V25I 


705 


V340I 


481 


V4366 


704 


V124 


705 


V167 


705 


V252 


705 


V341 


481 


V4369 


704 


VI25 


705 


V168 


705 


V253 


681 


V342 


481 


V437 


628 


VI 250 


705 


V169 


705 


V2540 


703 


V3500 


481 


V438 


705 


VI251 


705 


VI70 


705 


V254I 


703 


V3501 


481 


V4381 


704 


VI 252 


705 


V17I 


705 


V2542 


703 


V35I 


481 


V4382 


704 


VI 259 


705 


VI72 


705 


V2543 


703 


V352 


481 


V4389 


704 


VI26 


705 


V173 


705 


V2549 


703 


V3600 


481 


V440 


705 


V127 


705 


V174 


705 


V255 


703 


V360I 


481 


V441 


705 


VI 270 


705 


VI75 


705 


V258 


703 


V36I 


481 


V442 


705 


VI27I 


705 


V176 


705 


V259 


703 


V362 


481 


V443 


705 


VI 272 


705 


V177 


705 


V260 


705 


V3700 


481 


V444 


705 


VI 279 


705 


V178 


705 


V261 


703 


V370I 


481 


V445 


705 


VI30 


705 


V180 


705 


V262 


705 


V37I 


481 


V446 


705 


VI 300 


705 


V181 


705 


V263 


703 


V372 


481 


V447 


705 


VI30I 


705 


V182 


705 


V264 


703 


V3900 


481 


V448 


705 


VI 309 


705 


V183 


705 


V268 


703 


V3901 


481 


V449 


705 


VI31 


705 


V184 


705 


V269 


703 


V391 


481 


V450 


705 


VI32 


705 


V185 


705 


V270 


998 


V392 


481 


V4500 


704 


VI33 


705 


V186 


705 


V271 


998 


V400 


B 


V4501 


704 


238 


















Final Report 



■m 















Map Of ICD-9-CM 


Diagnosis Codes to PCGs 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


DX 


PCG 


V4502 


704 


V4977 


704 


V5789 


705 


V626 


B 


V699 


B 


V4509 


704 


V498 


705 


V579 


705 


V6281 


B 


V700 


701 


V451 


705 


V499 


705 


V580 


705 


V6282 


B 


V701 


B 


V452 


705 


V500 


705 


V581 


705 


V6289 


B 


V702 


B 


V453 


705 


V501 


705 


V582 


705 


V629 


B 


V703 


701 


V454 


705 


V502 


705 


V583 


704 


V630 


B 


V704 


701 


V455 


705 


V503 


705 


V584 


704 


V631 


B 


V705 


701 


V4551 


705 


V5041 


705 


V5841 


704 


V632 


B 


V706 


701 


V4552 


705 


V5042 


705 


V5849 


704 


V638 


B 


V707 


701 


V4559 


705 


V5049 


705 


V585 


541 


V639 


B 


V708 


701 


V456 


534 


V508 


705 


V5861 


576 


V640 


705 


V709 


701 


V4581 


705 . 


V509 


705 


V5869 


704 


V641 


705 


V7101 


B 


V4582 


704 . ■ 


V51 


635 


V588 


704 


V642 


705 


V7102 


B 


V4583 


704 


V520 


628 


V5881 


704 


V643 


705 


V7I09 


B 


V4589 


705 


V521 


628 


V5882 


998 


V650 


705 


V711 


705 


V460 


564 


V522 


705 


V5889 


704 


V651 


B 


V712 


705 


V461 


564 


V523 


541 


V589 


704 


V652 


B 


V7I3 


705 


V468 


705 


V524 


635 


V590 


705 


V653 


6S2 


V714 


705 


V469 


705 


V528 


628 


V5901 


705 


V654 


B 


V715 


L 


V470 


705 


V529 


628 


V5902 


705 


V6540 


B 


V716 


705 


V471 


705 


V530 


515 


V5909 


705 


V6541 


705 


V717 


705 


V472 


705 


V531 


534 


V591 


705 


V6542 


H 


V718 


705 


V473 


705 


V532 


544 


V592 


705 


V6543 


705 


V719 


705 


V474 


705 


V533 


575 


V593 


705 


V6544 


691 


V720 


532 


V475 


705 


V5331 


705 


V594 


705 


V6545 


A 


V721 


543 


V479 


705 


V5332 


705 


V595 


705 


V6549 


705 


V722 


541 


V480 


705 


V5339 


705 


V5% 


705 


V655 


B 


V723 


681 


V481 


705 


V534 


541 


V598 


705 


V658 


B 


V724 


681 


V482 


705 


V535 


596 


V599 


705 


V659 


B 


V725 


705 


V483 


705 


V536 


G 


V600 


B 


V660 


705 


V726 


705 


V484 


705 


V537 


628 


V60I 


B 


V661 


705 


V727 


705 


V485 


705 


V538 


622 


V602 


B 


V662 


705 


V728 


701 


V486 


705 


V539 


622 


V603 


B 


V663 


705 


V7281 


701 


V487 


705 


V540 


705 


V604 


B 


V664 


705 


V7282 


701 


V488 


705 


V548 


622 


V605 


B 


V665 


705 


V7283 


701 


V489 


705 


V549 


622 


V606 


B 


V666 


705 


V7284 


701 


V490 


705 


V550 


544 


V608 


B 


V6e9 


705 


V7285 


701 


V491 


705 


V551 


596 


V609 


B 


V670 


704 


V729 


701 


V492 


705 


V552 


596 


V610 


B 


V671 


704 


V730 


705 


V493 


705 


V553 


596 


V611 


B 


V672 


705 


V731 


705 


V494 


705 


V554 


596 


V6120 


B 


V673 


B 


V732 


705 


V495 


705 


V555 


G 


V6121 


L 


V674 


704 


V733 


705 


V4960 


704 


V556 


G 


V6129 


B 


V6751 


701 


V734 


705 


V4961 


704 


V557 


681 


V613 


B 


V6759 


704 


V735 


705 


V4962 


704 


V558 


705 


V6141 


B 


V676 


704 


V736 


705 


V4963 


704 


V559 


705 


V6149 


B 


V679 


704 


V738 


705 


V4964 


704 


V560 


705 


V615 


681 


V680 


B 


V7388 


705 


V4965 


704 


V561 


998 


V616 


B 


V681 


704 


V7389 


705 


V4966 


704 


V568 


662 


V6n 


B 


V682 


705 


V739 


705 


V4967 


704 


V570 


705 


V6I8 


B 


V6881 


705 


V7398 


705 


V4970 


704 


V571 


705 


V619 


B 


V6889 


705 


V7399 


705 


V4971 


704 


V572 


705 


V620 


B 


V689 


705 


V740 


705 


V4972 


704 


V5721 


705 


V621 


B 


V690 


705 


V741 


705 


V4973 


704 


V5722 


705 


V622 


B 


V691 


705 


V742 


705 


V4974 


704 


V573 


705 


V623 


B 


V692 


A 


V743 


705 


V4975 


704 


V574 


705 


V624 


B 


V693 


B 


V744 


705 


V4976 


704 


V5781 


622 


V625 


B 


V698 


B 


V745 


705 



The Development of a Physician Prospective Payment System for Ambulatory Care 



239 



APPENDIX F 



DX 


PCG 


V746 


705 


V748 


705 


V749 


705 


V750 


705 


V751 


705 


V752 


705 


V753 


705 


V754 


705 


V755 


705 


V756 


705 


V757 


705 


V758 


705 


V759 


705 


V760 


705 


V761 


705 


V762 


705 


V763 


705 


V7641 


705 


V7642 


705 


V7643 


705 


V7649 


705 


V768 


705 


V769 


705 


V770 


705 


V771 


705 


V772 


705 


V773 


705 


V774 


705 


V775 


705 


V776 


705 


V777 


705 


V778 


705 


V779 


705 


V780 


705 


V78I 


705 


V782 


705 


V783 


705 


V788 


705 


V789 


705 


V790 


705 


V791 


705 


V792 


705 


V793 


705 


V798 


705 


V799 


705 


V800 


705 


V801 


705 


V802 


705 


V803 


705 


V810 


705 


V811 


705 


V812 


705 


V813 


705 


V814 


705 


V815 


705 


V816 


705 


V820 


705 



DX 


PCG 


V821 


705 


V822 


705 


V823 


705 


V824 


705 


V825 


705 


V826 


705 


V828 


705 


V829 


705 



240 



Final Report 



Map of ICD-9-CM Diagnosis Codes to PCGs 



The Development of a Physician Prospective Payment System for Ambulatory Care 241 



APPENDIX F 



^^ Final Report 



APPENDIX G 



PCG Payment Weights 



The Development of a Physician Prospective Payment System for Ambulatory Care) 243 



o 
u 
a. 


a. 

U 
a. 


u 
o 


If 
ll 

9 


ll 


^ 1 

< 


ai 

< 




Descriptions 


1 


S 


c 


0.1A56 


0.«M 


o.:i6ii 


o.mi 


0.3655 


PHOTOCHEMOTHERAPY 


2 


s 


c 


1 .3475 


1.3447 


1.1164 


1.1179 


1.1592 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNULATION 


3 


s 


c 


3.1209 


3.1076 


2.3983 


2.3947 


2.2935 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNULATION 


4 


s 


c 


0.6881 


0.6849 


0.8833 


0.8787 


1.0188 


LEVEL 1 INCISION AND DRAINAGE 


5 


s 


c 


1.3612 


1..3542 


1 .6875 


\.blll 


2.0943 


LEVEL II INCISION AND DRAINAGE 


6 


s 


c 


0.3744 


0.3712 


0.4731 


0.4699 


0.4472 


SIMPLE NAIL AND PODIATRIC PROCEDURES 


7 


s 


c 


0.6141 


0.6099 


0.7579 


0.7534 


0.7725 


LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION 


8 


s 


c 


1 .5245 


1.5121 


1 .8667 


1.8546 


1.562 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


9 


s 


c 


2.708 


2.6858 


3,2695 


3.2481 


2.7442 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


10 


s 


c 


1.0903 


1.0827 


1.124 


1.1173 


1.1103 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


II 


s 


c 


2.674 


2,6552 


2.6294 


2.6141 


2.4967 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND NON-FIRST 
STAGE MOHS 


12 


s 


c 


5.2903 


5.248 


4.74.56 


4.7152 


4..3598 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


13 


s 


c 


5.9769 


5.9269 


7.0525 


7.0053 


7.2991 


FIRST STAGE MOHS PROCEDURE 


14 


s 


c 


1 .4234 


1.4224 


1 .4406 


1.4365 


1.7074 


LEVEL 1 SKIN REPAIR 


15 


s 


c 


5.2454 


5.2063 


4.9321 


4.9019 


4..5479 


LEVEL II SKIN REPAIR 


16 


s 


c 


10.771 


10.6812 


9.8216 


9.7559 


8.3235 


LEVEL III SKIN REPAIR 


17 


s 


c 


12.066 


11.9655 


11.1.575 


11.0834 


10.8764 


LEVEL IV SKIN REPAIR 


25 


s 


c 


19.0251 


18.8658 


14.8522 


14.7526 


14.1127 


BREAST RECONSTRUCTION AND MASTECTOMY 


26 


s 


c 


6.5778 


6.5307 


5.544 


5.5152 


5.181 


LEVEL 1 BREAST PROCEDURES 


27 


s 


c 


8.839 


8.7649 


7.7991 


7.7468 


6.9655 


LEVEL II BREAST PROCEDURES 


30 


s 


c 


6.1955 


6.1487 


5.011 


4.9805 


4.9388 


LEVEL 1 MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT 


31 


s 


c 


11.6098 


11.5126 


9.1478 


9.0864 


8.8201 


LEVEL II MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT 


32 


s 


c 


19.9461 


19.7791 


16.1928 


16.0842 


16.4322 


LEVEL III MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT. 


33 


s 


c 


6.1232 


6.0741 


4.8583 


4.8268 


4.2.541 


LEVEL 1 HAND AND FOOT PROCEDURE 


34 


s 


c 


7.5234 


7.4657 


6.2822 


6.2424 


5.83.54 


LEVEL II HAND AND FOOT PROCEDURE 


35 


s 


c 


14.1281 


14.0102 


11. .3977 


11.3213 


10.729 


LEVEL III HAND AND FOOT PROCEDURE 


36 


s 


c 


19.8979 


19.7325 


12.6622 


12.5775 


11.16 


ARTHROSCOPY 


37 


s 


c 


1.2339 


1.3791 


1.1077 


1.2785 


1.0933 


APPLICATION OF CASTS 


38 


p 


c 


0.4367 


0.433 1 


0.4573 


0.4542 


0.5638 


SPLINT, STRAPPING AND CAST REMOVAL 


39 


p 


c 


0.6027 0.5976 


0.6825 


0.6779 


0.8566 


UNNA BOOT APPLICATION 



> 
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a 

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o 



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a 

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3 
Dl 

3 

a 
m 

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5" 

3 



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< 

TJ 
B) 

>< 

3 

% 

*•+ 

u> 

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3 
o 

TJ 



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ll 

il 

s 


u s 

■§-3 

t/5 


i| 

u g 
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ll 

^ .-2 

1 "3 


(A 

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Descriptions (Continued) 


40 


s 


c 


U15 


2.6749 


2.m^ 


2.3943 


2.2.'i94 


CLOSED TREATMENT OP FRACTUkES AND blSLOCAI'IONS OE HAND, FOOT, AND 
TRUNK 


41 


s 


c 


6.2556 


6.2363 


6.1968 


6.1886 


5.9282 


CLOSED TREATMENT OF FRACTURES WITH MANIPULATION EXCEPT HAND, FOOT, 
AND TRUNK 


42 


s 


c 


4.1328 


4.1354 


3.7892 


3.8027 


3.7561 


CLOSED TREATMENT OF DISLOCATIONS AND FRACTURES WITHOUT MANIPULA- 
TION EXCEPT HAND, FOOT, AND TRUNK 


43 


s 


c 


11.1863 


1 1 .0955 


9.0278 


8.9706 


9.1261 


OPEN OR PERCUTANEOUS TREATMENT OF FRACTURES 


44 


s 


c 


12.1933 


12.1288 


9.5185 


9.4817 


9.5624 


BUNION PROCEDURES 


45 


s 


c 


15.9067 


15.7734 


12.2979 


12.2154 


12.2892 


ARTHROPLASTY WITHOUT PROSTHESIS 


46 


s 


c 


15.5535 


15.4232 


11.6196 


11.5417 


10.3149 


ARTHOPLASTY WITH PROSTHESIS 


47 


s 


c 


3.3084 


3.2809 


3.4681 


3.4452 


3.644 


HAND AND FOOT TENOTOMY 


48 


s 


c 


0.693 1 


0.733 


0.7315 


0.7532 


0.7696 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


-■iS 


p 


p 


0.2986 


0.2961 


0.2639 


0.2621 


0.257 


LEVEL 1 PULMONARY FUNCTION TESTS 


55 


p 


T 


0.2822 


0.2798 


0.2639 


0.2621 


0.2.544 


LEVEL 1 PULMONARY FUNCTION TESTS 


56 


p 


p 


0.3494 


0.3465 


0.3076 


0.3055 


0.3118 


LEVEL II PULMONARY FUNCTION TESTS 


56 


p 


T 


0.3885 


0.3852 


0.375 


0.3725 


0.3763 


LEVEL II PULMONARY FUNCTION TESTS 


57 


s 


P 


0.6315 


0.632 


0.5597 


0.5602 


0.5916 


LEVEL III PULMONARY FUNCTION, STRESS, AND CHALLENGE TESTS 


57 


s 


T 


0.8322 


0.8252 


0.8726 


0.8668 


0.893 


LEVEL III PULMONARY FUNCTION, STRESS, AND CHALLENGE TESTS 


58 


s 


C 


1.813 


1.8441 


1 .4938 


1 .5533 


1.6414 


NEEDLE AND CATHETER BIOPSY. ASPIRATION, LAVAGE AND INTUBATION 


59 


s 


C 


2.1116 


2.0975 


1.8845 


1.8739 


1 .6798 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOSCOPY WITH 
BIOPSY 


60 


s 


C 


6.4623 


6.4113 


4.8973 


4.8654 


4.2643 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


61 


s 


C 


12.4702 


12.4065 


8.305 


8.3379 


6.4405 


LEVEL III ENDOSCOPY OF THE UPPER AIRWAY 


62 


s 


C 


5.5549 


5.5 1 1 1 


4.881 


4.8488 


4.6764 


BRONCHOSCOPY 


63 


s 


C 


0.3764 


0.3865 


0.3138 


0.319 


0.3218 


RESPIRATORY THERAPY 


70 


p 


P 


0.2488 


0.2468 


0.199 


0.1976 


0.2073 


SIMPLE ECG 


70 


p 


T 


0.3169 


0.3143 


0.2799 


0.278 


0.2753 


SIMPLE ECG 


71 


p 


P 


0.913 


0.9053 


0.8154 


0.8099 


0.7236 


CONTINUOUS AND COMPLEX ECG AND BLOOD PRESSURE MONITORING 


71 


p 


T 


2.1302 


2.1124 


2.089 


2.075 


2.0113 


CONTINUOUS AND COMPLEX ECG AND BLOOD PRESSURE MONITORING 


72 


p 


P 


0.9054 


0.8978 


0.648 


0.6437 


0.5445 


NON-INVASIVE VASCULAR STUDIES 


72 


p 


T 


1.5239 


1.5112 


1.1943 


1.1863 


1 .0302 


NON-INVASIVE VASCULAR STUDIES 


73 


s 


P 


1.5721 


1.5654 


1.1087 


1.1062 


0.9941 


EXERCISE TOLERANCE TESTS 


73 


s 


T 


0.7171 


0.7111 


0.5896 


0.5856 


0.588 


EXERCISE TOLERANCE TESTS 






.1 



TJ 
O 

o 

< 

3 
n 

3 

S 

3- 



g 


a 


u 

o 


(J 4) 

n 

3 
C/3 


u g 

.t! t3 

a " 


o 
I " 

51 

< 


ll 




Descriptions (Continued) 


74 


1^ 


p 


1.2382 


1.2278 


1.0347 


\.0l11 


0.7339 


liCHOC'ARDIOdkAPHY 


74 


H 


1 


2.0741 


2.0568 


1 .9464 


1.9334 


1.7723 


ECHOCARDIOGRAPHY 


75 


S 


p 


8.1461 


8.0797 


5.611 


5.5743 


4.906 


CARDIAC ELECTROPHYSIOLOGIC TESTS AND PROCEDURES 


75 


S 


1 


1.671 


1.657 


1.6392 


1.6282 


1.6936 


CARDIAC ELECTROPHYSIOLOGIC TESTS AND PROCEDURES 


76 


s 


p 


7.4866 


7.4239 


5.7027 


5.6644 


4.6349 


DIAGNOSTIC CARDIAC CATHETERIZATION 


76 


s 


1 


8.6105 


8.5384 


10.9945 


10.9208 


15.1718 


DIAGNOSTIC CARDIAC CATHETERIZATION 


77 


s 


p 


1.8584 


1.8428 


0.7193 


0.7145 


1.0462 


TRANSCATHETER PROCEDURES 


11 


s 


T 


0.542 


0.5374 


0.8654 


0.8596 


6.5037 


TRANSCATHETER PROCEDURES 


78 


s 


c 


0.4064 


0.4037 


0.385 


0.3834 


0.4027 


INJECTIONS FOR CARDIAC CATHETERIZATION 


79 


s 


c 


13.3156 


13.2041 


12.1477 


12.0662 


11.33.54 


NON-CARDIAC ARTERIAL ANGIOPLASTIES AND TRANSCATHETER PROCEDURES 


80 


s 


c 


6.5012 


6.4468 


6.7162 


6.6711 


7.4548 


NON-CARDIAC VENOUS ANGIOPLASTIES AND TRANSCATHETER INFUSIONS 


81 


s 


c 


12.5581 


12.4529 


9.5174 


9.4536 


8.7212 


PACEMAKER INSERTION AND DEFIBRILLATOR REPLACEMENT 


82 


s 


c 


7.1692 


7.1161 


6.2664 


6.2295 


4.8562 


VASCULAR DEVICE INSERTIONS 


83 


s 


c 


4.32.39 


4.329 


3.572 


3..5837 


3.2076 


REMOVAL AND REVISION OF VASCULAR DEVICES AND PACEMAKERS 


84 


s 


c 


12.1382 


12.0388 


8.7849 


8.7293 


7.6689 


VASCULAR LIGATION 


85 


s 


c 


1.3129 


1.3074 


1.1882 


1.185 


1.2253 


SIMPLE VARICOSE VEIN PROCEDURES 


86 


s 


c 


16.4662 


16.3283 


13.6719 


13.5802 


1 1 .4276 


VASCULAR REPAIR AND FISTULA CONSTRUCTION 


87 


s 


c 


3.2154 


3.1893 


2.88.57 


2.8668 


3.0822 


RESUSCITATION AND CARDIOVERSION 


88 


s 


c 


0.6366 


0.6322 


0.5167 


0.5144 


0.461 


CARDIAC REHABILITATION 


89 


s 


c 


3.0535 


3.0307 


1.8784 


1.8671 


1.6394 


CENTRAL VENOUS CATHETER PLACEMENT 


90 


V 


c 


0,0706 


0.07 


0.0538 


0.0534 


0.0592 


LEVEL 1 VENIPUNCTURE AND BLOOD COLLECTION 


91 


p 


c 


0.4938 


0.4897 


0.3931 


0.3905 


0.3149 


LEVEL II VENIPUNCTURE, SIMPLE VENOUS CATHETER PLACEMENT, AND ARTE- 
RIAL PUNCTURES 


92 


s 


c 


3.6521 


3.625 


2.8481 


2.8313 


2.7158 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


93 


s 


c 


6.3211 


6.3025 


4.9131 


4.9102 


.5.192 


LEVEL II ARTERIAL CATHETER PLACEMENT 


94 


V 


c 


0.7632 


0.7568 


0,6815 


0.6769 


0.5938 


INFUSION THERAPY EXCEPT CHEMOTHERAPY 


95 


s 


c 


1.132 


1.2031 


1.0961 


1.16.32 


1.1414 


CHEMOTHERAPY BY EXTENDED OR COMPLEX INFUSION 


96 


s 


c 


0.7753 


1.0263 


0.7396 


0.9937 


0.711 


CHEMOTHERAPY EXCEPT BY EXTENDED INFUSION 


97 


p 


c 


0.2655 


0.2632 


0.1806 


0.1794 


0.0873 


SUBCUTANEOUS OR INTRAMUSCULAR CHEMOTHERAPY 


98 


s 


c 


0.925 


0.9361 


1.2238 


1.2351 


1..5051 


BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT 


99 


p 


c 


0.4118 


0.4083 


0.2824 0.2805 


0.2753 


THERAPEUTIC PHLEBOTOMY 



> 
■a 



a. 
O 



0) 
3 
Q. 

m 

< 

c 

0) 

#-* 

o 

3 

a 

■0 



< 
(D 

■0 
D> 

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3 
o 

3 
(0 

•< 
3 



"1 
O 

-*t 

a 
vt 

(A 

5' 

3 

s. 



S' 

(D 
(A 



to 





a. 




ll 

g 

s 


ll 

C/3 


5g 

P 

< 


ll 
o 5 




Descriptions (Continued) 


100 


s 


c 


3.4.S7 


3.6209 


2.6841 


2.7.513 


2.4294 


BLOOD AND BLOOD PRODUCT EXCHANCE 


101 


s 


c 


1.8951 


2.086 


0.886 


0.9687 


0.6302 


TRANSFUSIONS 


105 


s 


c 


4.9905 


4.9.553 


4.2239 


4.2032 


3.8.549 


SIMPLE LYMPH NODE PROCEDURES 


106 


s 


c 


13.3469 


13.2351 


11.3518 


1 1 .27.57 


10.6126 


DEEP LYMPH STRUCTURE, THYROID, AND NECK PROCEDURES 


115 


s 


p 


2.0247 


2.0079 


1.5745 


1..564 


1.7138 


ALIMENTARY TESTS 


115 


s 


T 


0.3886 


0.3853 


0.3114 


0.3093 


0.3369 


ALIMENTARY TESTS 


116 


s 


c 


5.4796 


5.4629 


4.7655 


4.7615 


3.7791 


SIMPLE UPPER Gl ENDOSCOPY 


117 


s 


c 


7.4055 


7.3471 


6.2392 


6.2001 


5.6642 


THERAPEUTIC UPPER 01 ENDOSCOPY OR INTUBATION 


118 


s 


c 


1.74.56 


1.7362 


1 .4255 


1.4188 


1.42 


ESOPHAGEAL DILATION WITHOUT ENDOSCOPY 


119 


s 


c 


6.8788 


6.8496 


5.5228 


5.5077 


5.1859 


LEVEL I COLONOSCOPY 


120 


s 


c 


9.2615 


9.2078 


8.0277 


7.9912 


7.5943 


LEVEL II COLONOSCOPY 


121 


s 


c 


2.706 


2.6863 


2.4305 


2.41.54 


2.0661 


PROCTOSIGMOIDOSCOPY WITH EXCISION OR BIOPSY 


122 


p 


c 


0.4917 


0.4876 


0.462 


0.4589 


0.5228 


SIMPLE ANOSCOPY 


123 


s 


c 


1.5961 


1.5837 


1.363 


1.3545 


1.3297 


ANOSCOPY WITH BIOPSY, THERAPUTIC ANOSCOPY, AND DIAGNOSTIC PROCTOSIG- 
MOIDOSCOPY 


124 


s 


c 


9.4533 


9.3754 


8.6271 


8.5702 


8.3159 


PERCUTANEOUS AND TRANSORAL BILLARY PROCEDURES 


125 


s 


c 


11.4027 


1 1 .3072 


8.3539 


8.2979 


7.6969 


HERNIA REPAIR EXCEPT UMBILICAL 


126 


s 


c 


9.58.34 


9.5095 


7.3714 


7.3223 


7.1816 


UMBILICAL HERNIAS, INTRAPERITONEAL, AND OTHER Gl PROCEDURES 


127 


s 


c 


2.0017 


1 .9859 


2.0255 


2.0124 


2.153 


LEVEL I ANAL AND RECTAL PROCEDURES 


128 


s 


c 


9.8719 


9.7892 


8.6896 


8.6313 


8.0676 


LEVEL II ANAL AND RECTAL PROCEDURES 


129 


s 


c 


12..5452 


12.4401 


7.6291 


7.578 


6.8019 


LEVEL 1 LAPAROSCOPIC PROCEDURES 


130 


s 


c 


20.8255 


20.6511 


13.2123 


13.1237 


12.7667 


LEVEL II LAPAROSCOPIC PROCEDURES 


131 


s 


c 


19.7907 


19.6249 


13.7412 


13.649 


12.6648 


RENAL EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY 


132 


s 


p 


1.393 


1.3834 


1.4412 


1 .4327 


1.4879 


URINARY STUDIES AND PROCEDURES 


132 


s 


T 


0.2884 


0.286 


0.3103 


0.3082 


0.3065 


URINARY STUDIES AND PROCEDURES 


133 


s 


c 


0.5329 


0.5544 


0.6149 


0.6.381 


0.7038 


URINARY CATHETERIZATION AND DILATATION 


134 


s 


c 


2.6919 


2.6784 


2.5.596 


2.5495 


2.3638 


LEVEL I GENITOURINARY PROCEDURES 


135 


s 


c 


5.7493 


5.7331 


5.0179 


5.0179 


4.4857 


LEVEL II GENITOURINARY PROCEDURES 


136 


s 


c 


13.6965 


13.5829 


12.1595 


12.0792 


10.8609 


LEVEL III GENITOURINARY PROCEDURES 


137 


p 


p 


0.9112 


0.9036 


0.9 


0.894 


1.1685 


UROFLOWMETRY 


137 


p 


T 


0.1062 


0.1053 


0.1117 


0.111 


0.1384 


UROFLOWMETRY 


145 


s 


c 


2.2133 


2.1947 


2.0186 


2.005 1 


1 .9683 


HEMODIALYSIS 


146 


s 


c 


2.0172 


2.0003 


1.7875 


1.77.55 


1 .7562 


PERITONEAL DIALYSIS 



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Descriptions (Continued) 


150 


s 


c 


9.1436 


9.067 


fi.7276 


8.6691 


6..5938 


TESTIS AND EPIDIDYMIS PkOCEDUkES 


151 


S 


c 


30.1869 


29.934 


24.8425 


24.6759 


17.8287 


INSERTION OF PENILE AND URINARY PROSTHESIS 


152 


S 


c 


4.1516 


4.1189 


3.5462 


3..5253 


3.2069 


LEVEL 1 PENILE PROCEDURES AND CIRCUMCISION 


153 


S 


c 


19.9749 


19.8076 


14.1942 


14.0991 


13.569 


LEVEL II PENILE PROCEDURES 


154 


s 


c 


4.003 


3.9753 


3.8372 


3.8124 


3.7795 


VASECTOMY AND VAS DEFERENS PROCEDURES 


155 


s 


c 


3.0978 


3.0758 


2.8.39 


2.8219 


1.977 


PROSTATE NEEDLE AND PUNCH BIOPSY 


160 


s 


c 














2.4686 


INSERTION OF SUBCUTANEOUS CONTRACEPTIVE 


161 


s 


c 


1.1037 


1.0945 


1.4132 


1.4037 


2.3785 


ARTIFICIAL FERTILIZATION 


162 


s 


p 


0.7361 


0.733 


0.5985 


0.5946 


0.6174 


PROCEDURES FOR PREGNANCY, NEONATAL CARE, AND FETAL TESTING 


162 


s 


T 


0.1605 


0.1592 


0.1564 


0.1553 


0.1648 


PROCEDURES FOR PREGNANCY, NEONATAL CARE, AND FETAL TESTING 


163 


s 


c 


6.9938 


6.9352 


4.6065 


4..5756 


4.7855 


TREATMENT OF SPONTANEOUS ABORTION 


164 


s 


c 


6.5304 


6.4757 


5.2541 


5.2189 


4.3352 


THERAPEUTIC ABORTION 


165 


s 


c 


10.42 


10.3328 


10.1989 


10.1305 


11.282 


VAGINAL DELIVERY 


166 


s 


c 


1 .8596 


1.8455 


1.36.55 


1.3568 


1.3131 


LEVEL 1 GYNECOLOGICAL PROCEDURES 


167 


s 


c 


6.4872 


6.4386 


4.3382 


4.3144 


4.0828 


LEVEL II GYNECOLOGICAL PROCEDURES 


168 


s 


c 


12.6558 


12.5497 


9.691 


9.626 


9.2778 


LEVEL III GYNECOLOGICAL PROCEDURES 


169 


s 


c 


6.0844 


6.0388 


4.0029 


3.9812 


3.4881 


DILATION AND CURETTAGE 


170 


s 


c 


9.0706 


8.9953 


3.932 


3.906 


3.3268 


HYSTEROSCOPY 


171 


H 


c 


1 .0628 


1.0539 


0.8234 


0.8179 


0.8374 


OTHER FEMALE REPRODUCTIVE PROCEDURES 


172 


p 


c 


0.2144 


0.2126 


0.3035 


0.3015 


0.416 


OBTAINING PAP SMEAR 


180 


s 


p 


3.1361 


3.1098 


2.5179 


2.5011 


2.9149 


EXTENDED EEC STUDIES AND SLEEP STUDIES 


180 


s 


l- 


4.59.32 


4.5547 


3.3041 


3.2819 


3.442 


EXTENDED EEC STUDIES AND SLEEP STUDIES 


181 


H 


p 


1.0361 


1.0274 


0.8932 


0.8872 


1.0225 


ELECTROENCEPHALOGRAM 


181 


P 


T 


0.9835 


0.9752 


0.8207 


0.81.52 


0.8916 


ELECTROENCEPHALOGRAM 


182 


s 


c 


1.5949 


1.5815 


1.4387 


1.429 


1.5494 


ELECTROCONVULSIVE THERAPY 


190 


s 


p 


2.7899 


2.7832 


1.9949 


2.0035 


0.5093 


LEVEL 1 NERVE AND MUSCLE TESTS 


190 


s 


I' 


0.8788 


0.8715 


0.6228 


0.6186 


0.1563 


LEVEL 1 NERVE AND MUSCLE TESTS 


191 


s 


p 


1 .4334 


1.423 


1.3534 


1.3456 


1.3011 


LEVEL II NERVE AND MUSCLE TESTS 


191 


s 


1' 


0.9802 


0.972 


0.9396 


0.9333 


0.8952 


LEVEL II NERVE AND MUSCLE TESTS 


192 


s 


c 


22.1055 


21.9204 


14.8661 


14.7664 


12.8533 


SPINAL CORD NEUROSTIMULATOR AND OTHER SPINAL CORD PROCEDURES 


193 


s 


c 


22.2054 


22.0194 


14.8065 


14.7072 


9.9458 


INSERTION OF NEUROSTIMULATOR AND OTHER DEVICES 


194 


s 


c 


0.8729 


0.8656 


1.2347 


1.2264 


1.6384 


NEUROSTIMULATOR ELECTRODE IMPLANTATION EXCEPT SPINAL 



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Descriptions (Continued) 


1^5 


s 


c 


11.798 


11.6992 


8.9889 


8.W86 


6.6443 


REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 


196 


S 


c 


12.6502 


12..5442 


12.2.362 


12.1541 


11.8816 


MAJOR NERVE REPAIRS AND GRAFTS 


197 


s 


c 


10.40.39 


10.3171 


6.4062 


6.3634 


6.0364 


NERVE REPAIR AND DESTRUCTION 


198 


s 


c 


3.4978 


3.4761 


2.4456 


2.4317 


1 .7855 


SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 


199 


p 


c 


1 .5223 


1 .5095 


1.0769 


1 .0697 


1.1718 


SPINAL TAP 


200 


s 


c 


4.5204 


4.4837 


2.9106 


2.8919 


2.3861 


SPINAL INJECTIONS FOR MYELOGRAPHY AND DISCOGRAPHGY 


201 


s 


c 


2.2773 


2.6532 


1.6379 


1.9911 


1.5181 


INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 


205 


s 


c 


0.6293 


0.6306 


0.7048 


0.701 


0.7423 


LEVEL I EYE TESTS AND PROCEDURES 


206 


s 


p 


1 .4497 


1.4801 


1.358 


1 .3924 


0.8803 


LEVEL II EYE TESTS AND PROCEDURES 


206 


s 


T 


0.899 


0.8915 


0.8822 


0.8763 


0.5725 


LEVEL II EYE TESTS AND PROCEDURES 


207 


s 


c 


0.6144 


0.6093 


0.8484 


0.8427 


0.9529 


OPHTHALMOLGICAL EXAMINATIONS 


208 


s 


p 


0.6997 


0.6939 


0.6967 


0.692 


0.5842 


MINOR EYE EXAMINATIONS 


208 


s 


T 


0.188 


0.1864 


0.1881 


0.1868 


0.1.574 


MINOR EYE EXAMINATIONS 


209 


s 


c 


1 .0623 


1 .0534 


1 .0269 


1.02 


0.9879 


FITTING OF CONTACT LENSES AND LOW VISION AIDS 


210 


p 


c 


0.3441 


0.3413 


0.4634 


0.4603 


0.5485 


FITTING OF SPECTACLE PROSTHESES 


211 


s 


c 


9.1484 


9.0712 


8.2589 


8.2033 


5. .509 1 


LASER EYE PROCEDURES EXCEPT RETINAL 


212 


s 


c 


13.0388 


12.9296 


12,3166 


12.234 


12.2981 


LASER RETINAL PROCEDURES 


213 


s 


c 


21.8864 


21.7031 


19.0277 


18.9 


15.1072 


CATARACT PROCEDURES 


214 


s 


c 


8.4135 


8.343 


6.7 


6.655 1 


5.5687 


LEVEL 1 ANTERIOR SEGMENT EYE PROCEDURES 


215 


s 


c 


10.1877 


10.1027 


9.0274 


8.9669 


8.2657 


LEVEL II ANTERIOR SEGMENT EYE PROCEDURES 


216 


s 


c 


17.337 


17.1918 


15.2987 


15.1961 


14.9411 


LEVEL III ANTERIOR SEGMENT EYE PROCEDURES 


217 


s 


c 


28.4805 


28.2419 


25.7.501 


25..5774 


19.7.521 


CORNEAL TRANSPLANT 


218 


s 


c 


12.9771 


12.8695 


11.6203 


1 1 .5426 


9.565 


LEVEL I VITRECTOMY AND POSTERIOR EYE PROCEDURE 


219 


s 


c 


35.1853 


34.8906 


30.9449 


30.7374 


25.1439 


LEVEL II VITRECTOMY AND POSTERIOR EYE PROCEDURES 


220 


s 


c 


14.826 


14.7018 


11. .56.57 


11.4881 


10.4495 


EXTRAOCULAR MUSCLE PROCEDURES 


221 


s 


c 


1 .6573 


1.6.563 


1.5916 


1 .5792 


1 .6449 


LEVEL I REPAIR AND PLASTIC PROCEDURES OF EYE 


222 


s 


c 


7.3077 


7.2465 


6.3651 


6.3224 


4..5445 


LEVEL II REPAIR AND PLASTIC PROCEDURES OF EYE 


22.1 


s 


c 


14.932 


14.807 


12.5265 


12.4425 


8.9454 


LEVEL III REPAIR AND PLASTIC PROCEDURES OF EYE 


230 


s 


c 


26.0744 


25.856 


25.8646 


25.6911 


24.7.544 


COCHLEAR DEVICE IMPLANTATION 


231 


s 


p 


0.8248 


0.8373 


0.5244 


0.5278 


0.5238 


OTORHINOLARYNGOLOGIC FUNCTION TESTS 


231 


s 


T 


0.3121 


0.3095 


0.2077 


0.2063 


0.2117 


OTORHINOLARYNGOLOGIC FUNCTION TESTS 


232 


s 


c 


1.2919 


1.2826 


1.2427 


1 .23.54 


1.3234 


NASAL CAUTERIZATION AND PACKING 


233 


s 


c 


2.2035 


2.191 


1 .8082 


1.7995 


1 .7646 


LEVEL I FACIAL AND ENT PROCEDURES 



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Descriptions (Continued) 


iM 


s 


c 


4.5165 


4.4792 


4.0026 


3.9761 


3.8048 


LEVEL 11 FACIAL AND ENT PkOCEbURES 


235 


s 


c 


11.0927 


11.0021 


8.9623 


8.9036 


8.2221 


LEVEL III FACIAL AND ENT PROCEDURES 


236 


s 


c 


23.3161 


23.1214 


18.7955 


18.67 


17.962 


LEVEL IV FACIAL AND ENT PROCEDURES 


237 


s 


c 


7.2941 


7.233 


5.1487 


5.1142 


4.5114 


TONSIL AND ADENOID PROCEDURES 


238 


\> 


c 


0.5856 


0.5807 


0.6077 


0.6036 


0.6101 


COMPLEX AUDIOMETRY 


239 


\> 


c 


0.381 


0.3778 


0.4334 


0.4305 


0.5322 


REMOVAL OF IMPACTED CERUMEN AND FOREIGN BODIES 


240 


p 


c 


0.3329 


0.3301 


0..3517 


0..3493 


0.3476 


AUDIOMETRY 


245 


s 


c 


2.0632 


2.0459 


1.8388 


1.8264 


1.9313 


THERAPEUTIC RADIATION TREATMENT PLANNING 


246 


s 


p 


1.7048 


1.6905 


1 .0223 


1.0155 


0.8927 


LEVEL 1 THERAPEUTIC RADIATION TREATMENT PREPARATION 


246 


s 


r 


1 .3847 


1.3731 


1 .0689 


1.0617 


1.0086 


LEVEL 1 THERAPEUTIC RADIATION TREATMENT PREPARATION 


247 


s 


F 


2.1038 


2.0862 


1 .2435 


1.2351 


1.1858 


LEVEL II THERAPEUTIC RADIATION TREATMENT PREPARATION 


247 


s 


T 


3.6276 


3.5972 


3.3263 


3.304 


3.5947 


LEVEL II THERAPEUTIC RADIATION TREATMENT PREPARATION 


248 


s 


p 


6.6529 


7.0567 


4.70.39 


.5.1692 


4.6859 


BRACHYTHERAPY AND COMPLEX RADIOELEMENT APPLICATIONS 


248 


s 


T 


7.22 


7.1595 


6.4078 


6.3648 


6.0262 


BRACHYTHERAPY AND COMPLEX RADIOELEMENT APPLICATIONS 


249 


s 


c 


4.8142 


4.7739 


3.2837 


3.2617 


3.0258 


RADIATION THERAPY MANAGEMENT 


250 


s 


c 


1 .6288 


1.6153 


1.3853 


1.3761 


1.4262 


RADIATION THERAPY 


251 


s 


p 


2.531 


2..5098 


1.5686 


1.5581 


1.4752 


HYPERTHERMIC THERAPIES 


251 


8 


1 


1.4013 


1.3896 


1 .9458 


1.9328 


1.8844 


HYPERTHERMIC THERAPIES 


252 


s 


c 


2.4089 


2.3887 


2.3605 


2.3446 


2.4398 


HYPERBARIC THERAPIES 


253 


s 


p 


2.6647 


2.8637 


1.972 


2.1392 


1.7133 


LEVEL I THERAPEUTIC NUCLEAR MEDICINE 


253 


,s 


T 


2.0146 


1.9977 


1.7217 


1.7101 


1.6336 


LEVEL 1 THERAPEUTIC NUCLEAR MEDICINE 


254 


s 


p 


1 .85.57 


2.3356 


1.2612 


1.26.37 


1.0983 


LEVEL II THERAPEUTIC NUCLEAR MEDICINE 


254 


s 


r 


1 .6477 


1.6339 


1.2979 


1.2892 


1.2206 


LEVEL II THERAPEUTIC NUCLEAR MEDICINE 


255 


s 


p 


2.8124 


4.2176 


I.8II2 


1.8932 


1.811 


RADIOPHARMACEUTICAL THERAPY OTHER THAN THYROID OR HEMATOLOGICAL 


255 


s 


r 


3.0603 


3.0346 


1.5903 


1..5796 


1.6336 


RADIOPHARMACEUTICAL THERAPY OTHER THAN THYROID OR HEMATOLOGICAL 


256 


s 


p 


1.1295 


1.12 


0.6693 


0.6648 


0.6361 


THERAPEUTIC RADIOLOGIC UROGRAPHIC PROCEDURES 


256 


s 


■I' 


1.216 


1.2058 


1.1612 


1.1534 


1.5931 


THERAPEUTIC RADIOLOGIC UROGRAPHIC PROCEDURES 


260 


s 


p 


0.62.54 


0.6223 


0.359 


0.3579 


0.3328 


FLUOROSCOPY 


260 


s 


1 


0.8875 


0.88 


0.8075 


0.8021 


0.8581 


FLUOROSCOPY 


261 


s 


p 


1.1708 


1.169 


0.83.34 


0.8346 


0.8225 


MYELOGRAPHY 


261 


s 


r 


3.2515 


3.2243 


3.5189 


3.4953 


3.766 


MYELOGRAPHY 


262 


s 


p 


0.7209 


0.7497 0.45.37 


0.4525 


0.4339 


DIAGNOSTIC UROGRAPHY 



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Descriptions (Continued) 


262 


s 


T 


1.5233 


1.5105 


1.1996 


1.1915 


1.2081 


DIAdNoSTlC UROGRAPHY 


263 


s 


P 


0.7263 


0.7214 


0.4266 


0.4257 


0.2216 


LEVEL 1 NON-IMAGING NUCLEAR MEDICINE 


263 


s 


T 


0.928 


0.9203 


0.83 


0.8244 


0.5093 


LEVEL 1 NON-IMAGING NUCLEAR MEDICINE 


264 


s 


P 


0.65 


0.6802 


0.3817 


0.408 1 


0.3025 


LEVEL II NON-IMAGING NUCLEAR MEDICINE 


264 


s 


T 


1.4288 


1.4168 


1.0086 


1.0019 


0.9215 


LEVEL II NON-IMAGING NUCLEAR MEDICINE 


265 


s 


P 


1 .6902 


1.7187 


1.2273 


1 .2532 


0.9275 


LEVEL 1 PLANAR 


265 


s 


T 


3.7639 


3.7324 


3.2606 


3.2387 


3.0686 


LEVEL 1 PLANAR 


266 


s 


P 


1 .2458 


1 .2592 


0.9254 


0.9383 


0.7514 


LEVEL II PLANAR 


266 


s 


T 


2.8949 


2.8706 


2.6005 


2.5831 


2.3681 


LEVEL II PLANAR 


267 


s 


P 


1.33.54 


1.359 


0.8045 


0.8423 


0.6045 


LEVEL 1 DIAGNOSTIC NUCLEAR MEDICINE 


267 


s 


T 


6.2828 


6.2302 


3.9196 


3.8933 


3.6648 


LEVEL 1 DIAGNOSTIC NUCLEAR MEDICINE 


268 


s 


P 


1 .7004 


1.7078 


1.0712 


1.0976 


0.931 


LEVEL II DIAGNOSTIC NUCLEAR MEDICINE 


268 


s 


T 


2.9382 


2.9136 


3.6777 


3.653 1 


3.5593 


LEVEL II DIAGNOSTIC NUCLEAR MEDICINE 


269 


s 


P 


2.2926 


2.3942 


1.6531 


1.7321 


1.3199 


LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 


269 


s 


T 


6.0092 


5.9589 


6.2977 


6.2554 


6.4617 


LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 


270 


s 


P 


I.5I3I 


1.5082 


0.9813 


0.9793 


0.9364 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


270 


s 


T 


2.6842 


2.6618 


2.8121 


2.7933 


3.6813 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


271 


s 


P 


2.III 


2.0964 


1.5878 


1.5821 


I..5743 


MAGNETIC RESONANCE ANGIOGRAPHY 


271 


s 


T 


7.6742 


7.6099 


7.2318 


7.1833 


6.9442 


MAGNETIC RESONANCE ANGIOGRAPHY 


272 


s 


P 


0.6929 


0.6911 


0.5083 


0.5067 


0.5078 


ARTHOGRAPHY 


272 


s 


T 


1.0912 


1.0821 


1.2299 


1.2217 


1.388 


ARTHOGRAPHY 


273 


p 


P 


1.079 


1 .0699 


0.843 


0.8374 


0.8353 


OBSTETRICAL ULTRASOUND 


273 


p 


T 


1.1827 


1.1728 


1.1124 


1.105 


1.1637 


OBSTETRICAL ULTRASOUND 


274 


p 


P 


1 .0295 


1 .0208 


0.7369 


0.7319 


0.6145 


VASCULAR ULTRASOUND 


274 


p 


T 


2.4648 


2.4441 


2.1715 


2.157 


2.1805 


VASCULAR ULTRASOUND 


275 


s 


P 


0.9058 


0.8983 


0.6447 


0.6404 


0.6186 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


275 


s 


T 


1.1674 


1.1576 


0.9264 


0.9202 


0.9206 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


276 


s 


P 


0.9935 


0.9855 


0.6403 


0.6363 


0.6265 


GUIDANCE UNDER ULTRASOUND 


276 


s 


T 


1.1615 


1.1517 


0.8966 


0.8906 


0.9.398 


GUIDANCE UNDER ULTRASOUND 


277 


s 


P 


2.2046 


2.187 


1.6119 


1.6012 


1.5579 


MAGNETIC RESONANCE IMAGING 


277 


s 


T 


9.6076 


9.5272 


9.2573 


9.1952 


9.2061 


MAGNETIC RESONANCE IMAGING 


278 


s 


P 


1.7119 


1.7288 


1 .0855 


1.0841 


1.032 


COMPUTERIZED AXIAL TOMOGRAPHY 


278 


s 


T 


4.5219 


4.4841 


3.7806 


3.7552 


3.7627 


COMPUTERIZED AXIAL TOMOGRAPHY 



.1 



TJ 

o 
o 

■D 

3 
m 

3 
»-* 

I 

(5 

3" 







u 
o 


SI '-' 


U s 
s - 

t/5 


P 

< 


l| 

U B 

■Si 

< 


-2 "i 

^ B 
—1 V 

^3 


Descriptions (Continued) 


m 


s 


p 


0.4091 


0.40.';6 


0.3641 


0.3617 


0.3076 


MAMMOOkAPHY 


279 


s 


v 


0.7522 


0.7459 


0.7642 


0.759 


0.6807 


MAMMOGRAPHY 


280 


s 


p 


0.8579 


0.85! 


0.7038 


0.6992 


0.6801 


DIGESTIVE RADIOLOGY 


280 


s 


r 


1.2355 


1.2251 


1.0971 


1.0897 


1.0938 


DIGESTIVE RADIOLOGY 


281 


p 


p 


0.2778 


0.2755 


0.1967 


0.1954 


0.1913 


PLAIN FILM 


281 


p 


T 


0.4452 


0.4415 


0.3642 


0.3618 


0.3711 


PLAIN FILM 


282 


s 


c 

















PET SCANS 


283 


s 


p 


0.9264 


0.9188 


0.5342 


0.5308 


0.4884 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


283 


s 


1 


1 .3674 


1.3559 


1.0319 


1.025 


1.1886 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


290 


s 


c 

















FULL DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE 


291 


s 


c 

















FULL DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 


292 


s 


c 

















HALF DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE 


293 


s 


c 

















HALF DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 


294 


s 


c 


1.1324 


1.1231 


1.4031 


1.394 


1.7228 


FAMILY PSYCHOTHERAPY 


295 


s 


c 


0.6268 


0.6222 


0.5092 


0.5066 


0.4385 


GROUP PSYCHOTHERAPY 


296 


s 


c 


0.8061 


0.8012 


0.8999 


0.8956 


0.9912 


SENILITY AND MENTAL RETARDATION THERAPY 


297 


s 


c 


1.2279 


1.2176 


1.4944 


1.4844 


1.5063 


EXTENDED INDIVIDUAL MENTAL HEALTH AND SUBSTANCE ABUSE VISIT FOR A 
PERSON UNDER 18 


298 


s 


c 


1 .0832 


1.0751 


1.3214 


1.3136 


1.4799 


EXTENDED INDIVIDUAL MENTAL HEALTH AND SUBSTANCE ABUSE VISIT FOR A 
PERSON 18 AND OLDER 


299 


s 


c 

















BRIEF INDIVIDUAL VISIT FOR SUBSTANCE ABUSE FOR A PERSON UNDER EIGH- 
TEEN 


300 


s 


c 


0.8562 


0.85 1 


0.8263 


0.8227 


0.9523 


BRIEF INDIVIDUAL VISIT FOR SUBSTANCE ABUSE FOR A PERSON EIGHTEEN AND 
OLDER 


301 


s 


c 


1.2534 


1.2429 


0.9756 


0.9691 


0.8627 


BRIEF INDIVIDUAL VISIT FOR THOUGHT AND PERSONALITY DISORDERS FOR A 
PERSON UNDER EIGHTEEN 


302 


s 


c 


0.6964 


0.6978 


0.7624 


0.7642 


0.8754 


BRIEF INDIVIDUAL VISIT FOR THOUGHT AND PERSONALITY DISORDERS FOR A 
PERSON EIGHTEEN AND OLDER 


303 


s 


c 


1.0555 


1.0467 


1 .0368 


1.0298 


1.0872 


BRIEF INDIVIDUAL VISIT FOR MENTAL HEALTH SYMFTONS AND / OR AFFECTIVE 
MENTAL DISORDERS FOR A PERSON UNDER 18 


304 


s 


c 


0.6131 


0.6105 


0.7048 


0.7016 


0.7874 


BRIEF INDIVIDUAL VISIT FOR MENTAL HEALTH SYMFTONS AND / OR AFFECTIVE 
MENTAL DISORDERS FOR A PERSON 18 AND OLDER 


305 


s 


c 

















TREATMENT FOR ABUSE, ASSAULT, OR RAPE FOR A PERSON UNDER 18 



■o 

1 

Q. 
S' 

Q 



o 



a 
a 
u> 

(5' 

3 
D) 

3 
□. 

m 

s 
s 

o 

3 

o 
o 

(A 



< 

n 

■0 
u 

•< 

3 

m 

3 
0) 

<< 

3 
o 

-I 

"D 

-1 
O 

a 
at 
lit 
o 






n 

9 

lit 



to 

Ol 
CO 





o 
u 

h— 


U 


u S 

s 
c« 




1- 

< 


* u 

1- 


11 

a: a 


Descriptions (Continued) 


:<06 


$ 


c 


0.9893 


0.981 


1.0472 


1.0402 


1.1563 


TREATMENT FOk ABUSE, ASSAULT, OR RAPE EOR A PERSON l8 AND OLDER 


307 


s 


c 


3.3624 


3.3347 


3.0126 


2.9929 


1.1502 


NEUROPSYCHOLOGICAL TESTING 


308 


s 


c 

















ACTIVITY THERAPY 


315 


s 


c 


1.0605 


1.0516 


1 .2922 


1.2835 


1.3045 


BIOFEEDBACK AND OTHER TRAINING 


316 


s 


c 


0.5442 


0.5406 


0.5784 


0.5762 


0.4497 


OCCUPATIONAL THERAPY 


317 


s 


c 


0.4007 


0.4006 


0.3688 


0.3687 


0.3598 


PHYSICAL THERAPY 


318 


s 


c 


0.7615 


0.755 1 


0.6297 


0.6254 


0.6324 


SPEECH THERAPY 


319 


s 


c 


0.268 


0.2658 


0.38 


0.3775 


0.4614 


MANIPULATION THERAPY 


325 


p 


c 


1.3478 


1 .3366 


1.0143 


1 .0075 


1.1027 


SIMPLE TUBE CHANGES AND INTRODUCTIONS 


326 


s 


c 


0.9667 


1.0161 


0.9261 


0.9497 


0.9824 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


327 


p 


c 


0.0912 


0.0904 


0.06 


0.0596 


0.0674 


INTRAMUSCULAR INJECTIONS 


328 


s 


c 


1 .9066 


1.8972 


2.2164 


2.207 1 


0.1057 


ALLERGY TESTS 


329 


s 


c 


0.2242 


0.2232 


0.3149 


0.3138 


0.2647 


ALLERGY INJECTIONS 


330 


p 


c 


0.0896 


0.0888 


0.0731 


0.0726 


0.0483 


LEVEL 1 IMMUNIZATION 


331 


p 


c 


0.6498 


0.6444 


0.8354 


0.8298 


0.9053 


LEVEL II IMMUNIZATION 


332 


p 


c 


1.3836 


1.372 


1.9127 


1.8998 


1.8232 


LEVEL III IMMUNIZATION 


335 


s 


c 


3.204 


3.1772 


1.769 


1 .7572 


1.8136 


LEVEL 1 ANESTHESIA 


336 


s 


c 


3.9103 


3.8776 


2.3068 


2.2914 


2.3701 


LEVEL II ANESTHESIA 


337 


s 


c 


5.1735 


5.1302 


3.1904 


3.169 


3.2995 


LEVEL III ANESTHESIA 


340 


p 


p 


0.357 


0.354 


0.3597 


0.3573 


0.3676 


ELECTRONIC ANALYSIS OF PACEMAKERS AND OTHER DEVICES 


340 


p 


T 


0.3347 


0.3319 


0.3554 


0.353 


0.3633 


ELECTRONIC ANALYSIS OF PACEMAKERS AND OTHER DEVICES 


341 


s 


c 

















PHYSICAN SUPERVISION OF ESRD 


342 


s 


c 

















PHYSICIAN PROVIDED HOME HEALTH CARE 


343 


s 


c 

















PHYSICIAN SUPERVISION OF HOME HEALTH CARE 


344 


s 


c 


0.6137 


0.6093 


0.662 


0.6583 


0.6786 


MEDICAL CONFERENCES, PHONE CALLS, REPORTS AND PATIENT TESTS 


350 


A 


p 


0.1721 


0.1706 


0.1252 


0.1243 


0.1255 


LEVEL 1 PATHOLOGY 


350 


A 


T 


0.0397 


0.0394 


0.0308 


0.0306 


0.0331 


LEVEL 1 PATHOLOGY 


356 


A 


c 


0.213 


0.2112 


0.18 


0.1788 


0.2359 


LEVEL 1 IMMUNOLOGY TESTS 


358 


A 


c 


0.209 


0.2072 


0.1807 


0.1795 


0.3303 


LEVEL 1 MICROBIOLOGY TESTS 


360 


A 


c 


0.357 


0.354 


0.3229 


0.3208 


0.3775 


LEVEL 1 ENDOCRINOLOGY TESTS 


362 


A 


c 


0.2205 


0.2186 


0.1903 


0.1891 


0.2205 


LEVEL 1 CHEMISTRY TESTS 


364 


A 


c 


0.1539 


0.1526 


0.1237 


0.1229 


0.1433 


BASIC CHEMISTRY TESTS 


369 


A 


c 


0.1538 


0.1525 


0.1084 


0.1077 


0.127 


LEVEL 1 CLOTTING TESTS 



TJ 
O 

o 

0) 

•< 

3 

(T> 

3 

I 

(5 

zr 







i 

U 
O 


V5 


ll 

W g 
x -a 

^ es 


51 

O 1- 

< 


11 
< 


ll 


Descriptions (Continued) 


371 


A 


C 


o.m^ 


0.1909 


0.1679 


0.1668 


0.1964 


LEVEL 1 HEMAI'OLOCJY TESTS 


373 


A 


c 


0.121 


0.12 


0.0829 


0.0824 


0.097 


URINALYSIS 


374 


A 


c 


0.1007 


0.0998 


0.0704 


0.0699 


0.0825 


BLOOD AND URINE DIPSTICK TESTS 


375 


A 


c 


0.226 


0.2241 


0.2282 


0.2267 


0.2676 


STREP TEST 


376 


A 


c 


0.1002 


0.0994 


0.062 


0.0616 


0.0726 


HEMATOCRIT AND HEMOGLOBIN 


377 


A 


c 


0.1367 


0.1356 


0.1035 


0.1028 


0.1208 


GLUCOSE 


431 


M 


c 


0.5973 


0.7297 


0.6545 


0.8164 


0.7068 


HEMATOLOGICAL MALIGNANCY 


432 


M 


c 


0.5126 


0.5135 


0.5819 


0.5844 


0.6256 


PROSTATIC MALIGNANCY 


433 


M 


c 


0.7254 


0.8226 


0.8041 


0.9193 


0.8663 


LUNG MALIGNANCY 


434 


M 


c 


0.6547 


0.6867 


0.7371 


0.7724 


0.7938 


BREAST MALIGNANCY 


435 


M 


c 


0.6823 


0.707 


0.7648 


0.7874 


0.8209 


Gl MALIGNANCY 


436 


M 


c 


0.5941 


0.5985 


0.6804 


0.6879 


0.7238 


SKIN MALIGNANCY 


437 


M 


c 


0.6862 


0.7579 


0.7518 


0.8286 


0.808 


OTHER MALIGNANCY 


451 


M 


c 


0.837 


0.8395 


0.8152 


0.8144 


0.8768 


POISONING 


460 


M 


c 


0.9777 


0.9716 


0.9312 


0.9261 


1.0025 


HEAD AND SPINE INJURY 


461 


M 


c 


0.6158 


0.616 


0.6336 


0.6321 


0.6789 


MINOR SKIN AND SOFT TISSUE INJURIES EXCEPT BURNS 


462 


M 


c 


0.737 


0.7359 


0,7082 


0.7063 


0.7589 


SKIN AND SOFT TISSUE INJURIES EXCEPT BURNS 


463 


M 


c 


0.6724 


0.6731 


0.7052 


0.7053 


0.7583 


FRACTURE, DISLOCATION AND SPRAIN OF FINGERS, TOES, AND TRUNK 


464 


M 


c 


0.7773 


0.7745 


0.7743 


0.7718 


0.8265 


FRACTURE. DISLOCATION AND SPRAIN EXCEPT FINGERS, TOES, AND TRUNK 


465 


M 


c 


0.5459 


0.5455 


0.5767 


0.5756 


0.6393 


BURNS 


466 


M 


c 


0.8133 


0.8107 


0.7951 


0.7916 


0.856 


OTHER INJURIES 


481 


M 


c 


0.7185 


0.7165 


0.8097 


0.8064 


0.8615 


NEONATES AND CONGENITAL ANOMALIES 


491 


M 


c 


0.612 


0.6069 


0.6206 


0.6165 


1.2783 


ROUTINE PRENATAL CARE 


492 


M 


c 


1.0136 


1.0052 


0.881 


0.875 1 


1.0862 


MATERNAL ANTEPARTUM COMPLICATION 


493 


M 


c 


0.5546 


0.5502 


0.7468 


0.7422 


1.3624 


ROUTINE POSTPARTUM CARE 


494 


M 


c 


0.9583 


0.9503 


0.8894 


0.8835 


0.9641 


MATERNAL POSTPARTUM COMPLICATION 


501 


M 


c 


0.5916 


0.5933 


0.6503 


0.6506 


0.7072 


LEVEL 1 INFECTIOUS DISEASES 


502 


M 


c 


1.3436 


1.3.393 


1.2145 


1.2126 


1.3244 


LEVEL II INFECTIOUS DISEASE 


503 


M 


c 


0.5957 


0.5933 


0.7081 


0.7046 


0.7643 


INFECTIOUS DISEASES OF GENITAL ORGANS - FEMALES 


504 


M 


c 


0.5325 


0.539 


0.5921 


0.5963 


0.6417 


INFECTIOUS DISEASES OF GENITAL ORGANS - MALES 


511 


M 


c 


0.8992 


0.8928 


0.9417 


0.9361 


1.0155 


TIA, CVA AND OTHER CEREBROVASCULAR EVENTS 


512 


M 


c 


0.7083 


0.7114 


0.7506 


0.7494 


0.8137 


HEADACHE 



> 
■o 

a. 



a 



o 
o 
in 

(5' 

3 
01 

=1 

a 

m 

< 

0) 

c 

0) 

I 

o 

■* 
D) 

O 
V) 

1 



0) 

>< 

3 
n 

s 

(/) 

>< 

a 

(D 

3 



o 



(A 
O 

3 
U 

w 



to 

en 





a. 


U 
O 


o S 

. -a 

9 


ll 
en 




ll 
U a 

n 

< 


^1 


Descriptions (Continued) 


51:^ 


M 


c 


0.7737 


0.7676 


0.7927 


0.7877 


0.8624 


EPILEMY 


514 


M 


c 


0.9612 


0.9542 


0.959 


0.9531 


1 .0342 


NON TRAUMATIC LOSS OF CONSCIOUSNESS AND CONVULSIONS 


515 


M 


c 


0.7408 


0.7378 


0.8324 


0.8288 


0.8838 


LEVEL 1 DISEASES OF THE NERVOUS SYSTEM 


516 


M 


c 


0.75 1 


0.7549 


0.8264 


0.8291 


0.8838 


LEVEL II DISEASES OF THE NERVOUS SYSTEM 


531 


M 


c 


0.6349 


0.6296 


0.8485 


0.8429 


0.9371 


CATARACTS 


532 


M 


c 


0..5583 


0.5536 


0.7631 


0.758 


0.9176 


REFRACTION DISORDER 


533 


M 


c 


0.4676 


0.4646 


0.5715 


0.5683 


0.6187 


CONJUNCTIVITIS AND OTHER SIMPLE EXTERNAL EYE INFLAMMATION 


534 


M 


c 


0.5215 


0.5173 


0.6569 


0.6527 


0.7136 


EYE DISEASES EXCEPT CATARACT,REFRACTION DISORDER & CONJUNCTIVITIS 


540 


M 


c 


0.5315 


0.5336 


0.6186 


0.6192 


0,6836 


INFLUENZA, URI AND ENT INFECTIONS - PEDIATRIC 


541 


M 


c 


0.6063 


0.6101 


0.6059 


0.6115 


0.6765 


DENTAL DISEASE 


542 


M 


c 


0.4785 


0.4903 


0.5793 


0.5862 


0.6322 


INFLUENZA, URI AND ENT INFECTIONS - NON-PEDIATRIC 


543 


M 


c 


0.653 


0.6485 


0.7914 


0.7868 


0.8433 


HEARING LOSS 


544 


M 


c 


0.5366 


0.5399 


0.6468 


0.6476 


0,6986 


OTHER LEVEL 1 EAR, NOSE, THROAT AND MOUTH DISEASES 


545 


M 


c 


0.6382 


0.6365 


0.7118 


0.7091 


0.7695 


OTHER LEVEL II EAR, NOSE, THROAT AND MOUTH DISEASES 


560 


M 


c 


0.5556 


0.551 


0.4717 


0.4686 


0.4772 


EMPHYSEMA, CHRONIC BRONCHITIS, AND ASTHMA - PEDIATRIC 


561 


M 


c 


0..5683 


0.5729 


0.6672 


0.6685 


0.7333 


EMPHYSEMA, CHRONIC BRONCHITIS, AND ASTHMA - NON - PEDIATRIC 


562 


M 


c 


0.9049 


0.9154 


0.9006 


0.9092 


0.9857 


PNEUMONIA 


563 


M 


c 


0.734 


0.7325 


0.8194 


0.8163 


0,8746 


LEVEL I RESPIRATORY DIS EXC EMPHYSEMA,CHR BRONCHITIS & ASTHMA 


564 


M 


c 


1 ,0867 


1.0817 


1.0495 


1.045 


1,1367 


LEVEL II RESPIRATORY DIS EXC EMPHYSEMA,CHR BRONCHITIS & ASTHMA 


569 


M 


c 


0.5049 


0,5025 


0.6188 


0.6156 


0.6608 


BENIGN AND UNSPECIFIED HYPERTENSION 


570 


M 


c 


0.5564 


0.5546 


0.6849 


0.6817 


0.7228 


HYPERTENSION WITH COMPLICATIONS 


571 


M 


c 


0.6885 


0.6861 


0.7722 


0.7683 


0.8337 


CONGESTIVE HEART FAILURE AND ISCHEMIC HEART DISEASE 


573 


M 


c 

















CHEST PAIN W CARDIAC ENZYMES TO RULE OUT MYOCARDIAL INFARCT 


574 


M 


c 


0.9285 


0.9226 


0.9513 


0.946 


1.0205 


CHEST PAIN WO CARDIAC ENZYMES TO RULE OUT MYOCARDIAL INFARCT 


575 


M 


c 


0..593 


0.5896 


0.7035 


0.6997 


0.7509 


LEVEL 1 CARDIOVASCULAR DIS EXC CHF,ISCHEM1C HEART DIS & HYPERTN 


576 


M 


c 


0.6884 


0.6848 


0.7796 


0.7755 


0.8256 


LEVEL II CARDIOVASCULAR DIS EXC CHF,ISCHEMIC HEART DIS & HYPERTN 


590 


M 


c 


0.6714 


0.6658 


0.6837 


0.6792 


0.7801 


NONINFECTIOUS GASTROENTERITIS - PEDIATRIC 


591 


M 


c 


0.6808 


0.6801 


0.7513 


0.7486 


0.8103 


NONINFECTIOUS GASTROENTERITIS - NON-PEDIATRIC 


592 


M 


c 


0.6795 


0.676 


0.7545 


0.7506 


0.8149 


ULCERS, GASTRITIS AND ESOPHAGITIS 


593 


M 


c 


0,7788 


0.7743 


0.8434 


0.8388 


0.9038 


HEPATOBILIARY DISEASE 


594 


M 


c 


0.6703 


0.6657 


0.7931 


0,7884 


0.8504 


HERNIA 


595 


M 


c 


0.6285 


0.6248 


0.7202 


0.7165 


0.774 


HEMORRHOIDS AND OTHER ANAL-RECTAL DISEASES 


596 


M 


c 


0.7344 


0.7309 


0.7994 


0.7956 


0.8583 


OTHER LEVEL 1 GASTROINTESTINAL DISEASES 



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Descriptions (Continued) 


597 


M 


c 


0.8821 


0,8799 


0.9167 


0.914 


0.9815 


OTHEtl LEVEL II GASTROINTESTINAL DISEASES 


611 


M 


c 


1.0514 


1.0478 


1.0084 


1.0044 


1.1045 


MAJOR SIGNS, SYMPTOMS AND FINDINGS 


621 


M 


c 


0.6737 


0.6748 


0.7385 


0.738 


0.7993 


BACK DISORDERS 


622 


M 


c 


0.5658 


0.574 


0.6618 


0.6636 


0.7147 


LEVEL 1 MUSCULOSKELETAL DISEASES EXCEPT BACK DISORDERS 


628 


M 


c 


0.6714 


0.6739 


0.7644 


0.7647 


0.8137 


LEVEL II MUSCULOSKELETAL DISEASES EXCEPT BACK DISORDERS 


631 


M 


c 


0.4598 


0.4564 


0.6057 


0.6018 


0.6308 


DISEASE OF NAILS 


632 


M 


c 


0.5122 


0.5098 


0.5821 


0.5798 


0.6327 


CHRONIC SKIN ULCER 


633 


M 


c 


0.5219 


0.5314 


0.6042 


0.6115 


0.6565 


"CELLULITIS, IMPETIGO AND LYMPHANGITIS" 


634 


M 


c 


0.64.55 


0.6408 


0.7657 


0.761 


0.8171 


BREAST DISEASES 


635 


M 


c 


0.4849 


0.4888 


0.5851 


0.5859 


0.6222 


LEVEL 1 SKIN DISEASES 


636 


M 


c 


0.5194 


0.5249 


0.6243 


0,6271 


0.6701 


LEVEL II SKIN DISEASES 


650 


M 


c 


0.5057 


0.5038 


0.6125 


0.6095 


0.6705 


LEVEL 1 DIABETES 


651 


M 


^ 


0.6389 


0.638 


0.7168 


0.7144 


0.7814 


LEVEL II DIABETES 


652 


M 


c 


0.5391 


0.5377 


0.6586 


0.6555 


0.7036 


LEVEL 1 ENDOCRINE, NUTRITIONAL & METABLIC DISEASE, INCL OBESITY AND 
EXC DIABETES 


653 


M 


c 


0.7767 


0.7796 


0.8212 


0.8221 


0.8811 


LEVEL 11 ENDOCRINE.NUTRIT & METABOLIC DIS EXC DIABETES & OBESITY 


654 


M 


c 


1.1973 


1.1916 


1.0941 


1.0898 


1.2028 


FLUID AND ELECTROLYTE DISORDERS 


661 


M 


c 


0.5553 


0.5568 


0,6322 


0.6318 


0.6902 


URINARY TRACT INFECTION 


662 


M 


c 


0.7485 


0.8465 


0.7885 


0.8762 


0.8383 


RENAL FAILURE 


663 


M 


c 


0.5948 


0.5928 


0.6838 


0.6818 


0.7369 


LEVEL I URINARY DIS EXC URINARY TRACT INFECTN & RENAL FAILURE - 
FEMALES 


664 


M 


c 


0.5644 


0.5613 


0.6619 


0.6584 


0.7072 


LEVEL 1 URINARY DIS EXC URINARY TRACT INFECTN & RENAL FAILURE - MALES 


665 


M 


c 


0.6884 


0.686 


0.7506 


0.7478 


0.8015 


LEVEL II URINARY DIS EXC URINARY TRACT INFECTN & RENAL FAILURE 


672 


M 


c 


0.5443 


0.5536 


0.6445 


0.6463 


0.6912 


MALE REPRODUCTIVE DISEASES EXCEPT BENIGN PROSTATIC HYPERTROPHY 


681 


M 


c 


0.6568 


0.6552 


0.7876 


0.7844 


0.8463 


GYNECOLOGIC DISEASES 


691 


M 


c 


0.76.36 


0.7724 


0.7944 


0.7979 


0.8324 


HIV INFECTION 


692 


M 


c 


0.5156 


0.5835 


0.6068 


0.664 


0.646 


ANEMIA 


693 


M 


c 


0.6096 


0.6144 


0.7059 


0.7109 


0.7546 


OTHER LEVEL 1 IMMUNOLOGIC AND HEMATOLOGIC DISEASE 


694 


M 


c 


0.6057 


0.8819 


0.6691 


0.9706 


0.708 


OTHER LEVEL II IMMUNOLOGIC AND HEMATOLOGIC DISEASE 


701 


M 


c 


0.6912 


0.6867 


0.8427 


0.8381 


0.9154 


ADULT MEDICAL EXAMINATION 


702 


M 


c 


0.898 


0.8904 








0.9055 


WELL CHILD CARE 


703 


M 


c 


0.545 


0.5643 


0.5847 


0.5921 0.6501 1 


CONTRACEPTION AND PROCREATIVE MANAGEMENT 



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Descriptions (Continued) 


704 


M 


c 


0.4782 


0.4747 


0.567.5 


0..5639 


0.6276 


AfTEkCAkE 


705 


M 


c 


0.6652 


0.6653 


0.74 


0.739 


0.7925 


NONSPECIFIC SIGNS & SYMPTOMS & OTH CONTACTS W HEALTH SVCS 


721 


M 


c 


0.7815 


0.7762 


0.8117 


0.8101 


0.8857 


UNKNOWN CAUSE OF MORTALITY. 


750 


S 


c 


0.4344 


0.4.307 


0.3846 


0.382 





DENTAL EXAMINATION 


751 


S 


c 

















PREVENTIVE DENTAL PROCEDURES 


752 


S 


c 

















DENTAL PROSTHESIS 


753 


S 


c 

















LEVEL I DENTAL RESTORATIONS 


754 


S 


c 

















LEVEL II DENTAL RESTORATIONS 


755 


S 


c 

















ENDODONTICS 


756 


S 


c 

















PERIODONTICS 


757 


S 


c 

















LEVEL I PROSTHODONTICS 


758 


S 


c 

















LEVEL II PROSTHODONTICS 


759 


S 


c 

















DENTAL MAXILLOFACIAL PROSTHETICS 


760 


S 


c 


2.7837 


2.7604 


2.7029 


2.6848 





LEVEL I ORAL AND MAXILLOFACIAL SURGERY 


761 


S 


c 

















LEVEL II ORAL AND MAXILLOFACIAL SURGERY 


762 


S 


c 

















LEVEL I ORTHODONTICS 


763 


s 


c 

















LEVEL II ORTHODONTICS 


764 


s 


c 

















OTHER DENTAL VISITS 


765 


p 


c 


0.9485 


0.9405 


1.3416 


1.3326 





MINOR MISCELLANEOUS DENTAL PROCEDURES 


766 


p 


c 

















DENTAL PLAIN FILM 


767 


p 


c 

















DENTAL ANESTHESIA 



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Appendix G 



258 

Final Report 




APPENDIX H 



PCG Pairs Exempt from Multiple 
Significant Procedure Discounting 



The Development of a Physician Prospective Payment System for Ambulatory Care 259 



PCGl 


PCGl Desc 


PCG2 


PCG2 Desc 


2 


LRVEL 1 1'EkcUtAMEoUS MKEbLB tilOKY. AShkATION, ANdcANNTF- 
L ATI ON 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHEIER PLACEMENT 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


93 


LEVEL 11 ARTERIAL CATHETER PLACEMENT 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


260 


FLUOROSCOPY 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


262 


DIAGNOSTIC UROGRAPHY 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


272 


ARTHOGRAPHY 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, ANDCANNU- 
LATION 


274 


VASCULAR ULTRASOUND 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


276 


GUIDANCE UNDER ULTRASOUND 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


279 


MAMMOGRAPHY 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


.1 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


260 


FLUOROSCOPY 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


262 


DIAGNOSTIC UROGRAPHY 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


272 


ARTHOGRAPHY 



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PCGl 


PCGl Desc 


PCG2 


PCG2 Desc 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


274 


VASCULAR ULTRASOUND 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CANNU- 
LATION 


276 


GUIDANCE UNDER ULTRASOUND 

' ^ . 1 


3 


LEVEL 11 PERCUTANEOUS NEEDLE BIOPSY ASPIRATION, AND CANNU- 
LATION 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


3 


LEVEL 11 PERCUTANEOUS NEEDLE BIOPSY ASPIRATION, AND CANNU- 
LATION 


279 


MAMMOGRAPHY 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY ASPIRATION, AND CANNU- 
LATION 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


3 


LEVEL II PERCUTANEOUS NEEDLE BIOPSY ASPIRATION, AND CANNU- 
LATION 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


93 


LEVEL 11 ARTERIAL CATHETER PLACEMENT 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


250 


RADIATION THERAPY 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


260 


FLUOROSCOPY 


7 


LEVEL i SKIN DEBRIDEMENT AND DESTRUCTION 


262 


DIAGNOSTIC UROGRAPHY 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


272 


ARTHOGRAPHY 


7 


LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION 


274 


VASCULAR ULTRASOUND 


7 


LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


7 


LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION 


276 


GUIDANCE UNDER ULTRASOUND 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


279 


MAMMOGRAPHY 


7 


LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


7 


LEVEL 1 SKIN DEBRIDEMENT AND DESTRUCTION 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


250 


RADIATION THERAPY 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


260 


FLUOROSCOPY 


8 


LEVEL 11 DEBRIDEMENT AND DESTRUCTION 


262 


DIAGNOSTIC UROGRAPHY 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 




MAGNETIC RESONANCE ANGIOGRAPHY 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


272 


ARTHOGRAPHY 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


274 


VASCULAR ULTRASOUND 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


276 


GUIDANCE UNDER ULTRASOUND 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 



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U3 I 






PCGl 


PCGl Desc 


PCG2 


PCG2 Desc 


8 


LnVEL II DEBRIDEMENT AND DESTRUCTION 


279 


MAMMOGRAPHY 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


8 


LEVEL II DEBRIDEMENT AND DESTRUCTION 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


250 


RADIATION THERAPY 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


260 


FLUOROSCOPY 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


262 


DIAGNOSTIC UROGRAPHY 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


272 


ARTHOGRAPHY 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


274 


VASCULAR ULTRASOUND 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


276 


GUIDANCE UNDER ULTRASOUND 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


279 


MAMMOGRAPHY 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


9 


LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTION 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


93 


LEVEL 11 ARTERIAL CATHETER PLACEMENT 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


250 


RADIATION THERAPY 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


260 


FLUOROSCOPY 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


262 


DIAGNOSTIC UROGRAPHY 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


10 


LEVEL I SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


272 


ARTHOGRAPHY 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


274 


VASCULAR ULTRASOUND 


10 


LEVEL I SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


10 


LEVEL I SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


276 


GUIDANCE UNDER ULTRASOUND 


10 


LEVEL I SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


10 


LEVEL I SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


279 


MAMMOGRAPHY 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


10 


LEVEL 1 SKIN EXCISION AND BIOPSY OF SKIN AND SOFP TISSUE 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


11 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


11 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


11 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


250 


RADIATION THERAPY 


11 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


260 


FLUOROSCOPY 



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PCGl 


PCGl Desc 


PCG2 


PCG2 Desc 


II 


LEVEL 11 SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


262 


DIAGNOSTIC UROGRAPHY 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFF TISSUE, AND 
NON-FIRST STAGE MOHS 


272 


ARTHOGRAPHY 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


274 


VASCULAR ULTRASOUND 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


276 


GUIDANCE UNDER ULTRASOUND 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


279 


MAMMOGRAPHY 


II 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


11 


LEVEL II SKIN EXCISION, BIOPSY OF SKIN AND SOFT TISSUE, AND 
NON-FIRST STAGE MOHS 


326 


SIMPLE VASCULAR AND NON- VASCULAR INJECTIONS 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


250 


RADIATION THERAPY 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


260 


FLUOROSCOPY 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


262 


DIAGNOSTIC UROGRAPHY 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


272 


ARTHOGRAPHY 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


274 


VASCULAR ULTRASOUND 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


276 


GUIDANCE UNDER ULTRASOUND 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


279 


MAMMOGRAPHY 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


12 


LEVEL III SKIN EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


26 


LEVEL I BREAST PROCEDURES 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


26 


LEVEL I BREAST PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


26 


LEVEL I BREAST PROCEDURES 


260 


FLUOROSCOPY 


26 


LEVEL 1 BREAST PROCEDURES 


262 


DIAGNOSTIC UROGRAPHY 


26 


LEVEL I BREAST PROCEDURES 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 



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PCGl Desc 


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LEVEL 1 BREAST PROCEDURES 


272 


ARTHOGRAPHY 


26 


LEVEL 1 BREAST PROCEDURES 


274 


VASCULAR ULTRASOUND 


26 


LEVEL I BREAST PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


26 


LEVEL 1 BREAST PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


26 


LEVEL I BREAST PROCEDURES 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


26 


LEVEL 1 BREAST PROCEDURES 


279 


MAMMOGRAPHY ■ , . > 


26 


LEVEL 1 BREAST PROCEDURES 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


26 


LEVEL I BREAST PROCEDURES 


326 


SIMPLE VASCULAR AND NON- VASCULAR INJECTIONS 


27 


LEVEL II BREAST PROCEDURES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


27 


LEVEL II BREAST PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


27 


LEVEL II BREAST PROCEDURES 


260 


FLUOROSCOPY 


27 


LEVEL II BREAST PROCEDURES 


262 


DIAGNOSTIC UROGRAPHY 


27 


LEVEL II BREAST PROCEDURES 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


27 


LEVEL II BREAST PROCEDURES 


272 


ARTHOGRAPHY 


27 


LEVEL II BREAST PROCEDURES 


274 


VASCULAR ULTRASOUND 


27 


LEVEL II BREAST PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


27 


LEVEL II BREAST PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


27 


LEVEL II BREAST PROCEDURES 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


27 


LEVEL II BREAST PROCEDURES 


279 


MAMMOGRAPHY 


27 


LEVEL II BREAST PROCEDURES 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


27 


LEVEL II BREAST PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


260 


FLUOROSCOPY 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


262 


DIAGNOSTIC UROGRAPHY 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


272 


ARTHOGRAPHY 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


274 


VASCULAR ULTRASOUND 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


276 


GUIDANCE UNDER ULTRASOUND 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


279 


MAMMOGRAPHY 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


48 


ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


58 


NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBA- 
TION 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


58 


NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBA- 
TION 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 



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PCG2 Desc 


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NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBA- 
TION 


260 


FLUOROSCOPY 


58 


NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBA- 
TION 


262 


DIAGNOSTIC UROGRAPHY 


58 


NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBA- 
TION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 

1 


58 


NEEDLE AND CATHETER BIOPSY ASPIRATION, LAVAGE AND INTUBA- 
TION 


272 


ARTHOGRAPHY 


58 


NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBA- 
TION 


274 


VASCULAR ULTRASOUND 


58 


NEEDLE AND CATHETER BIOPSY ASPIRATION, LAVAGE AND INTUBA- 
TION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


58 


NEEDLE AND CATHETER BIOPSY. ASPIRATION, LAVAGE AND INTUBA- 
TION 


276 


GUIDANCE UNDER ULTRASOUND 


58 


NEEDLE AND CATHETER BIOPSY ASPIRATION, LAVAGE AND INTUBA- 
TION 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


58 


NEEDLE AND CATHETER BIOPSY ASPIRATION, LAVAGE AND INTUBA- 
TION 


279 


MAMMOGRAPHY 


58 


NEEDLE AND CATHETER BIOPSY ASPIRATION, LAVAGE AND INTUBA- 
TION 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


58 


NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBA- 
TION 


326 


SIMPLE VASCULAR AND NON- VASCULAR INJECTIONS 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


260 


FLUOROSCOPY 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


262 


DIAGNOSTIC UROGRAPHY 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


272 


ARTHOGRAPHY 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


274 


VASCULAR ULTRASOUND 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


276 


GUIDANCE UNDER ULTRASOUND 



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PCG2 


PCGl Desc 


59 


LEVfeL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


278 


COMPUTERIZED AXIAL ToMoGrApHY 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


279 


MAMMOGRAPHY 


59 


LEVEL I ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


59 


LEVEL 1 ENDOSCOPY OF THE UPPER AIRWAY AND MINOR LARYNGOS- 
COPY WITH BIOPSY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


260 


FLUOROSCOPY 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


262 


DIAGNOSTIC UROGRAPHY 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


272 


ARTHOGRAPHY 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


274 


VASCULAR ULTRASOUND 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


276 


GUIDANCE UNDER ULTRASOUND 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


279 


MAMMOGRAPHY 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


60 


LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


62 


BRONCHOSCOPY 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


62 


BRONCHOSCOPY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


62 


BRONCHOSCOPY 


260 


FLUOROSCOPY 


62 


BRONCHOSCOPY 


262 


DIAGNOSTIC UROGRAPHY 


62 


BRONCHOSCOPY 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


62 


BRONCHOSCOPY 


272 


ARTHOGRAPHY 


62 


BRONCHOSCOPY 


274 


VASCULAR ULTRASOUND 


62 


BRONCHOSCOPY 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


62 


BRONCHOSCOPY 


276 


GUIDANCE UNDER ULTRASOUND 


62 


BRONCHOSCOPY 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


62 


BRONCHOSCOPY 


279 


MAMMOGRAPHY 


62 


BRONCHOSCOPY 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


62 


BRONCHOSCOPY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


73 


EXERCISE TOLERANCE TESTS 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


73 


EXERCISE TOLERANCE TESTS 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


73 


EXERCISE TOLERANCE TESTS 


263 


LEVEL I NON-IMAGING NUCLEAR MEDICINE 


73 


EXERCISE TOLERANCE TESTS 


264 


LEVEL II NON-IMAGING NUCLEAR MEDICINE 


73 


EXERCISE TOLERANCE TESTS 


265 


LEVEL I PLANAR 



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PCG2 Desc 


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EXERCISE TOLERANCE TESTS 


266 


LEVEL II PLANAR 


17. 


EXERCISE TOLERANCE TESTS 


267 


LEVEL 1 DIAGNOSTIC NUCLEAR MEDICINE 


73 


EXERCISE TOLERANCE TESTS 


268 


LEVEL II DIAGNOSTIC NUCLEAR MEDICINE 


73 


EXERCISE TOLERANCE TESTS 


269 


LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 


73 


EXERCISE TOLERANCE TESTS 


273 


OBSTETRICAL ULTRASOUND 


73 


EXERCISE TOLERANCE TESTS 


274 


VASCULAR ULTRASOUND ' 


73 


EXERCISE TOLERANCE TESTS 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


73 


EXERCISE TOLERANCE TESTS 


276 


GUIDANCE UNDER ULTRASOUND 


73 


EXERCISE TOLERANCE TESTS 


326 


SIMPLE VASCULAR AND NON- VASCULAR INJECTIONS 


76 


DIAGNOSTIC CARDIAC CATHETERIZATION 


78 


INJECTIONS FOR CARDIAC CATHETERIZATION 


76 


DIAGNOSTIC CARDIAC CATHETERIZATION 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


76 


DIAGNOSTIC CARDIAC CATHETERIZATION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


77 


TRANSCATHETER PROCEDURES 


78 


INJECTIONS FOR CARDIAC CATHETERIZATION 


77 


TRANSCATHETER PROCEDURES 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


77 


TRANSCATHETER PROCEDURES 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


78 


INJECTIONS FOR CARDIAC CATHETERIZATION 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


78 


INJECTIONS FOR CARDIAC CATHETERIZATION 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


79 


NON-CARDIAC ARTERIAL ANGIOPLASTIES AND TRANSCATHETER 
PROCEDURES 


78 


INJECTIONS FOR CARDIAC CATHETERIZATION 


79 


NON-CARDIAC ARTERIAL ANGIOPLASTIES AND TRANSCATHETER 
PROCEDURES 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


79 


NON-CARDIAC ARTERIAL ANGIOPLASTIES AND TRANSCATHETER 
PROCEDURES 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


81 


PACEMAKER INSERTION AND DEFIBRILLATOR REPLACEMENT 


260 


FLUOROSCOPY 


82 


VASCULAR DEVICE INSERTIONS 


274 


VASCULAR ULTRASOUND 


82 


VASCULAR DEVICE INSERTIONS 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


82 


VASCULAR DEVICE INSERTIONS 


276 


GUIDANCE UNDER ULTRASOUND 


83 


REMOVAL AND REVISION OF VASCULAR DEVICES AND PACEMAKERS 


260 


FLUOROSCOPY 


83 


REMOVAL AND REVISION OF VASCULAR DEVICES AND PACEMAKERS 


274 


VASCULAR ULTRASOUND 


83 


REMOVAL AND REVISION OF VASCULAR DEVICES AND PACEMAKERS 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


83 


REMOVAL AND REVISION OF VASCULAR DEVICES AND PACEMAKERS 


276 


GUIDANCE UNDER ULTRASOUND 


84 


VASCULAR LIGATION 


274 


VASCULAR ULTRASOUND 


84 


VASCULAR LIGATION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


84 


VASCULAR LIGATION 


276 


GUIDANCE UNDER ULTRASOUND 


85 


SIMPLE VARICOSE VEIN PROCEDURES 


274 


VASCULAR ULTRASOUND 


85 


SIMPLE VARICOSE VEIN PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


85 


SIMPLE VARICOSE VEIN PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


86 


VASCULAR REPAIR AND FISTULA CONSTRUCTION 


274 


VASCULAR ULTRASOUND 


86 


VASCULAR REPAIR AND FISTULA CONSTRUCTION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 



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PCGl Desc 


PCG2 


PCG2 Desc 


86 


VASCULAR REPAlk AND FlStULA CONSTRUCTION 


116 


GUIDANCE UNDER ULTRASoUnD 


95 


CHEMOTHERAPY BY EXTENDED OR COMPLEX INFUSION 


96 


CHEMOTHERAPY EXCEPT BY EXTENDED INFUSION 


115 


ALIMENTARY TESTS 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


115 


ALIMENTARY TESTS 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


115 


ALIMENTARY TESTS 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


115 


ALIMENTARY TESTS 


276 


GUIDANCE UNDER ULTRASOUND i 


115 


ALIMENTARY TESTS 


280 


DIGESTIVE RADIOLOGY 


115 


ALIMENTARY TESTS 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


116 


SIMPLE UPPER 01 ENDOSCOPY 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


116 


SIMPLE UPPER 01 ENDOSCOPY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


116 


SIMPLE UPPER 01 ENDOSCOPY 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


116 


SIMPLE UPPER 01 ENDOSCOPY 


276 


GUIDANCE UNDER ULTRASOUND 


116 


SIMPLE UPPER 01 ENDOSCOPY 


280 


DIGESTIVE RADIOLOGY 


116 


SIMPLE UPPER GI ENDOSCOPY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


117 


THERAPEUTIC UPPER GI ENDOSCOPY OR INTUBATION 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


117 


THERAPEUTIC UPPER GI ENDOSCOPY OR INTUBATION 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


117 


THERAPEUTIC UPPER GI ENDOSCOPY OR INTUBATION 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


117 


THERAPEUTIC UPPER GI ENDOSCOPY OR INTUBATION 


276 


GUIDANCE UNDER ULTRASOUND 


117 


THERAPEUTIC UPPER GI ENDOSCOPY OR INTUBATION 


280 


DIGESTIVE RADIOLOGY 


117 


THERAPEUTIC UPPER GI ENDOSCOPY OR INTUBATION 


326 


SIMPLE VASCULAR AND NON- VASCULAR INJECTIONS 


118 


ESOPHAGEAL DILATION WITHOUT ENDOSCOPY 


280 


DIGESTIVE RADIOLOGY 


118 


ESOPHAGEAL DILATION WITHOUT ENDOSCOPY 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


118 


ESOPHAGEAL DILATION WITHOUT ENDOSCOPY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


119 


LEVEL 1 COLONOSCOPY 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


119 


LEVEL 1 COLONOSCOPY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


119 


LEVEL 1 COLONOSCOPY 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


119 


LEVEL I COLONOSCOPY 


276 


GUIDANCE UNDER ULTRASOUND 


119 


LEVEL I COLONOSCOPY 


280 


DIGESTIVE RADIOLOGY 


119 


LEVEL 1 COLONOSCOPY 


326 


SIMPLE VASCULAR AND NON- VASCULAR INJECTIONS 


120 


LEVEL II COLONOSCOPY 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


120 


LEVEL II COLONOSCOPY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


120 


LEVEL II COLONOSCOPY 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


120 


LEVEL II COLONOSCOPY 


276 


GUIDANCE UNDER ULTRASOUND 


120 


LEVEL II COLONOSCOPY 


280 


DIGESTIVE RADIOLOGY 


120 


LEVEL II COLONOSCOPY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


121 


PROCTOSIGMOIDOSCOPY WITH EXCISION OR BIOPSY 


280 


DIGESTIVE RADIOLOGY 


123 


ANOSCOPY WITH BIOPSY THERAPUTIC ANOSCOPY, AND DIAGNOSTIC 
PROCTOSIGMOIDOSCOPY 


280 


DIGESTIVE RADIOLOGY 


124 


PERCUTANEOUS ANDTRANSORAL BILLARY PROCEDURES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 



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PCGl 


PCGl Desc 


FCG2 


PCG2 Dcsc 


124 


PERCUTANEOUS ANDTRANSORAL BILLARY PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


124 


PERCUTANEOUS ANDTRANSORAL BILLARY PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


124 


PERCUTANEOUS ANDTRANSORAL BILLARY PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


124 


PERCUTANEOUS ANDTRANSORAL BILLARY PROCEDURES 


280 


DIGESTIVE RADIOLOGY 


124 


PERCUTANEOUS ANDTRANSORAL BILLARY PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


129 


LEVEL 1 LAPAROSCOPIC PROCEDURES 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CAN- 
NULATION 


129 


LEVEL 1 LAPAROSCOPIC PROCEDURES 


166 


LEVEL 1 GYNECOLOGICAL PROCEDURES 


130 


LEVEL II LAPAROSCOPIC PROCEDURES 


2 


LEVEL 1 PERCUTANEOUS NEEDLE BIOPSY, ASPIRATION, AND CAN- 
NULATION 


130 


LEVEL II LAPAROSCOPIC PROCEDURES 


166 


LEVEL I GYNECOLOGICAL PROCEDURES 


134 


LEVEL 1 GENITOURINARY PROCEDURES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


134 


LEVEL 1 GENITOURINARY PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


134 


LEVEL 1 GENITOURINARY PROCEDURES 


273 


OBSTETRICAL ULTRASOUND 


134 


LEVEL I GENITOURINARY PROCEDURES 


274 


VASCULAR ULTRASOUND 


134 


LEVEL 1 GENITOURINARY PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


134 


LEVEL 1 GENITOURINARY PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


134 


LEVEL 1 GENITOURINARY PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


135 


LEVEL II GENITOURINARY PROCEDURES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


135 


LEVEL II GENITOURINARY PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


135 


LEVEL II GENITOURINARY PROCEDURES 


273 


OBSTETRICAL ULTRASOUND 


135 


LEVEL II GENITOURINARY PROCEDURES 


274 


VASCULAR ULTRASOUND 


135 


LEVEL II GENITOURINARY PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


135 


LEVEL II GENITOURINARY PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


135 


LEVEL II GENITOURINARY PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


136 


LEVEL III GENITOURINARY PROCEDURES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


136 


LEVEL III GENITOURINARY PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


136 


LEVEL III GENITOURINARY PROCEDURES 


273 


OBSTETRICAL ULTRASOUND 


136 


LEVEL III GENITOURINARY PROCEDURES 


274 


VASCULAR ULTRASOUND 


136 


LEVEL III GENITOURINARY PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


136 


LEVEL III GENITOURINARY PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


136 


LEVEL III GENITOURINARY PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


150 


TESTES AND EPIDIDYMIS PROCEDURES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


150 


TESTES AND EPIDIDYMIS PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


150 


TESTES AND EPIDIDYMIS PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


155 


PROSTATE NEEDLE AND PUNCH BIOPSY 


262 


DIAGNOSTIC UROGRAPHY 


155 


PROSTATE NEEDLE AND PUNCH BIOPSY 


395 


CLASS FIVE CHEMOTHERAPY DRUGS 


180 


EXTENDED BEG STUDIES AND SLEEP STUDIES 


55 


LEVEL I PULMONARY FUNCTION TESTS 


180 


EXTENDED EEG STUDIES AND SLEEP STUDIES 


56 


LEVEL II PULMONARY FUNCTION TESTS 



TJ 

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3 

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o 

c 
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5" 
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PCGl 


PCGl Desc 


PCG2 


PCG2 Desc 


180 


Extended Eeg Studies And sLEEP s tUdIes 


57 


LEVEL III PULMoNAKY EUNCTlON, STRESS, AND CHALLENGE 
TESTS 


190 


LEVEL 1 NERVE AND MUSCLE TESTS 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


190 


LEVEL 1 NERVE AND MUSCLE TESTS 


276 


GUIDANCE UNDER ULTRASOUND 


191 


LEVEL il NERVE AND MUSCLE TESTS 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


191 


LEVEL II NERVE AND MUSCLE TESTS 


276 


GUIDANCE UNDER ULTRASOUND 


195 


REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


195 


REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


195 


REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 


200 


SPINAL INJECTIONS FOR MYELOGRAPHY AND DISKOGRAPHGY 


195 


REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 


260 


FLUOROSCOPY 


195 


REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 


261 


MYELOGRAPHY 


195 


REVISION OR REMOVAL OF NEUROLOGICAL DEVICES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


198 


SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


198 


SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


198 


SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 


200 


SPINAL INJECTIONS FOR MYELOGRAPHY AND DISKOGRAPHGY 


198 


SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 


260 


FLUOROSCOPY 


198 


SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 


261 


MYELOGRAPHY 


198 


SPINAL INJECTIONS AND INTRACRANIAL INJECTIONS AND TAPS 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


201 


INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


201 


INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


201 


INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 


200 


SPINAL INJECTIONS FOR MYELOGRAPHY AND DISKOGRAPHGY 


201 


INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 


260 


FLUOROSCOPY 


20! 


INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 


261 


MYELOGRAPHY 


201 


INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


211 


LASER EYE PROCEDURES EXCEPT RETINAL 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


211 


LASER EYE PROCEDURES EXCEPT RETINAL 


276 


GUIDANCE UNDER ULTRASOUND 


212 


LASER RETINAL PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


212 


LASER RETINAL PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


245 


THERAPEUTIC RADIATION TREATMENT PLANNING 


249 


RADIATION THERAPY MANAGEMENT 


246 


LEVEL 1 THERAPEUTIC RADIATION TREATMENT PREPARATION 


245 


THERAPEUTIC RADIATION TREATMENT PLANNING 


246 


LEVEL 1 THERAPEUTIC RADIATION TREATMENT PREPARATION 


249 


RADIATION THERAPY MANAGEMENT 


247 


LEVEL II THERAPEUTIC RADIATION TREATMENT PREPARATION 


245 


THERAPEUTIC RADIATION TREATMENT PLANNING 


247 


LEVEL II THERAPEUTIC RADIATION TREATMENT PREPARATION 


249 


RADIATION THERAPY MANAGEMENT 


253 


LEVEL 1 THERAPUTIC NUCLEAR MEDICINE 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


253 


LEVEL 1 THERAPUTIC NUCLEAR MEDICINE 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


253 


LEVEL 1 THERAPUTIC NUCLEAR MEDICINE 


326 


SIMPLE VASCULAR AND NON- VASCULAR INJECTIONS 


254 


LEVEL II THERAPUTIC NUCLEAR MEDICINE 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


254 


LEVEL II THERAPUTIC NUCLEAR MEDICINE 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


254 


LEVEL II THERAPUTIC NUCLEAR MEDICINE 326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 



> 

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•< 
3 
(« 

3 

v> 

•< 

(A 

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(D 

3 



> 
3 

C 

a 

o 

o 

u 



PCGl 


PCGl Desc 


PCG2 


PCG2 Desc 


256 


THERAPUTIC RADIOLOGIC UROORAPHIC PROCEDURES 


92 


LfeVBL 1 ARTEklAL AND VENOUS CATHETER PLACEMENT 


256 


THERAPUTIC RADIOLOGIC UROORAPHIC PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


256 


THERAPUTIC RADIOLOGIC UROORAPHIC PROCEDURES 


275 


DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 


256 


THERAPUTIC RADIOLOGIC UROORAPHIC PROCEDURES 


276 


GUIDANCE UNDER ULTRASOUND 


256 


THERAPUTIC RADIOLOGIC UROORAPHIC PROCEDURES 


280 


DIGESTIVE RADIOLOGY 


256 


THERAPUTIC RADIOLOGIC UROORAPHIC PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


260 


FLUOROSCOPY 


92 


LEVEL I ARTERIAL AND VENOUS CATHETER PLACEMENT 


260 


FLUOROSCOPY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


260 


FLUOROSCOPY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


262 


DIAGNOSTIC UROGRAPHY 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


262 


DIAGNOSTIC UROGRAPHY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


262 


DIAGNOSTIC UROGRAPHY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


267 


LEVEL I DIAGNOSTIC NUCLEAR MEDICINE 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


267 


LEVEL 1 DIAGNOSTIC NUCLEAR MEDICINE 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


267 


LEVEL 1 DIAGNOSTIC NUCLEAR MEDICINE 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


269 


LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


269 


LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


269 


LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


273 


OBSTETRICAL ULTRASOUND 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


279 


MAMMOGRAPHY 


270 


DIAGNOSTIC ANGIOGRAPHY AND VENOGRAPHY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


273 


OBSTETRICAL ULTRASOUND 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


278 


COMPUTERIZED AXIAL TOMOGRAPHY 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


279 


MAMMOGRAPHY 


271 


MAGNETIC RESONANCE ANGIOGRAPHY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


272 


ARTHOGRAPHY 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


272 


ARTHOGRAPHY 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


272 


ARTHOGRAPHY 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 


283 


MISCELLANEOUS RADIOLOGICAL PROCEDURES 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


92 


LEVEL 1 ARTERIAL AND VENOUS CATHETER PLACEMENT 


326 


SIMPLE VASCULAR AND NON-VASCULAR INJECTIONS 


93 


LEVEL II ARTERIAL CATHETER PLACEMENT 



TJ 
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APPENDIX H 



^^ Final Report 



• 



APPENDIX I 



PCG Payment Simulation Fomiulas 



The Development of a Physician Prospective Payment System for Ambulatory Care 273 



Appendix I 



PCG Payment Simulation Overview 

The objective of the PCG payment simulation is to compute a PCG based payment amount for each 
visit and compare the PCG payment to historical charges for the visit. The simulation will be per- 
formed on a budget neutral basis with total payments across all visits under the PCGs being equal to 
the total historical charges across all visits. The performance of the PCG payment model will be com- 
pared using the statistic R-. Multiple simulations will be performed with alternative formulations of 
the PCG payment model (e.g., different methods of computing the PCG payment weights). The ratio 
of PCG payment to historical charges will also be computed for specific subsets of visits (e.g., visits 
treated by physicians in a particular specialty). 

Computing PCG Payment Weights Based on Submitted Charges or Allowed 
Charges 

PCG weights will be calculated using only those visits whose most significant line (MSL) is either a 
Significant Procedure, Medical Visit, or Professional Ancillary. In addition, only those incidental and 
ancillary procedures defined as incidental or members of the limited or extended sets of PCGs are to 
be included in the calculations. Weights are not computed for incidental PCGs in any model. 

V(/,g, t) = Dollar based measure of resource use for visit / in significant proce- 
dure or medical PCG g for service class t. The computation of 
V(/,g,r) for significant procedure PCGs will be restricted to those 
visits which have a single significant procedure PCG. A single sig- 
nificant procedure visit is a visit with either a single PCG with a 
combined service class, a single PCG with a professional service 
class, a single PCG with a technical service class, or a visit with 
two PCGs which are a combination of one professional service 
class and one technical service class for the same PCG. 

For the purpose of calculating weights using visits with only a single significant procedure, the 
most significant line (MSL) will be used. If the visit has both professional and technical service 
classes for the same PCG present, the MSL will refer to both lines. 

There will be four different bases for ^(i,g,t) 

• Submitted charges for the most significant line (MSL) 

• Submitted charges for the MSL plus incidental, medical/surgical supplies and phar- 
macy submitted charges 

• Allowed charges for the MSL 

• Allowed charges for the MSL plus incidental, medical/surgical supplies and phar- 
macy allowed charges 

Each of the four V(/,g,r)'s can be used to compute a payment weight for each PCG. 

Take the log of V{i,g,t) and for all visits in each PCG and compute the trim point value as the 
mean plus three standard deviations above the mean. Exclude all visits whose values of the log of 
V(/,g,r) exceeds the trim point value. Compute the trimmed non log transformed average submit- 
ted charge or allowed charge for each PCG. 



274 



Final Report 



i.,.:.r 



PCG Payment Simulation Formulas 



T(g, t) = Trimmed average visit submitted charge or allowed charge for PCG 
g for service class t 

The average submitted charge or allowed charge must also be computed for professional ancillar- 
ies and ancillary PCGs. The payment weights for professional ancillary and ancillary PCGs are 
computed using all occurrences of the professional ancillary or ancillary PCG. The count of pro- 
fessional ancillary and ancillary PCGs refer to the number of occurrences of the PCG and not the 
number of visits. 

Y(i,g,t) = submitted charge or allowed charge for i''' occurrence of profes- 
sional ancillary or ancillary PCG g for service class t 

Using the log of Y(i,g,t) compute the trim point for each professional ancillary or ancillary PCG 
in the same manner as was done for medical and significant procedure PCGs 

H(g,r) = trimmed average submitted charge or allowed charge for profes- 
sional ancillary or ancillary PCG g for service class t. 

The trinmied average submitted charges or allowed charges (i.e., T(g,t) and H(g,r)) are then nor- 
malized to create a payment weight by dividing T(g,r) and H(g,r) by 

^ N(g,OT(g,0 

e^ m.s 

X N(g./) 
g€ m.s 

where N(g,f) is the number of visits for PCG g for service class t, and m is the set of visits with a 
medical PCG and s is the set of visits with a single significant procedure PCG. After normaliza- 
tion T(g,t) is the payment weight for medical and significant procedure PCGs and H(g,r) is the 
payment weight for professional ancillary and ancillary PCGs. 

Components of PCG Payment Weights for Significant Procedure, Medical, Pro- 
fessional Ancillary and Ancillary PCGs 

Once payment weights based on submitted charges or allowed charges have been computed for 
each PCG, then each payment weight must be subdivided into three components (i.e., practice, 
work and malpractice). The CPT codes in some PCGs are not covered under RBRVS and there- 
fore, do not have any assigned RVUs. If a PCG does not have an RVU value, one will be assigned 
along with a set of factors apportioning that RVU between its work, practice and malpractice com- 
ponents. 

R(p,t,c) = RVU for CPT code p with class t for component c where compo- 
nent c is practice, work or malpractice 

y{p,t,c) = Fraction of RVU associated with component c for CPT code p with 

class / 

V(p,t,c) = — ^-^ '- 



J^R{p,',c) 



The Development of a Physician Prospective Payment System for Ambulatory Care 275 



Appendix I 



N(p,g,t) = Number of occurrences of CPT code p with class t in PCG g 
'P(gJ,c) = Fraction of RVU associated with component c for PCG g class t 

J^N(p,g,t)V{p,t,c) 

Normalize F(i, t, c) for each g and t to insure that ^F{g, t, c) = i.o 

c 

PCG Payment Simulation Formulas 

Wg,t,c) = Visit payment weight for PCG g in service class t for 
component c 

Where W(g,t,c) is computed as 

W(g,/,c) = T(g,/)F(g,r,c) 

W(g,;,c) = mg,t)F(g,t,c) 

I = Discount factor for payment when site is not office 

D{g,g) = Discount factor for multiple significant procedures. If there is more 
than one significant procedure PCG present, then the PCG with the 
highest weight will be given 100% of the weight and all other sig- 
nificant procedure PCGs will be given 50% of their weight. The fol- 
lowing exceptions will be made in the application of the discount 
factor. If the highest weight PCG is either a professional or techni- 
cal component of a PCG, one complementary component of the 
same PCG will also be given a weight of 100%. If the highest 
weight PCG is in a designated pair of PCGs, the other PCG in the 
designated pair will also be given a weight of 100%. If the other 
PCG has multiple components, they will also be given a weight of 
100%. 



B = 



Multiplier to convert payment weights to dollars on a budget neutral 

basis 



There will be a file of component significant procedure combinations which will not be subject to 
multiple significant procedure discounting. 

P(/) = PCG payment for /''' visit 
C(/) = Historical charge for /''' visit 



Let 



276 



Final Report 



PCG Payment Simulation Formulas 







1= professional 




2= technical 


c = 


3= complete 





1 = work 

2 = practice 

3 = malpractice 

4 = total 



Compute W(g,rj for each visit for each PCG as follows 



Class (t) 


Site 




1 


office 


"^(8,1,4) 


1 


other 


W(g,J,J)+W(g,l,3)+lW(g.l,2) 


2 


office 


^(g,2,4) 


2 


other 


W(g,2,J)+V/(g,2,3)+m(g,2,2) 


3 


office 


"^(8,3.4) 


3 


other 


W(g,3, 1)+W(g,3,3)+IW(g,3,2) 



For each visit a single W(g,t) will be computed for each PCG. Thus, a visit is described by a list of 
PCGs with each PCG having a weight associated with it. Note that the same PCG which occurs 
multiple times may have a different weight for the same visit depending on the class associated 
with each of the PCGs. 

a(h) = Subset of ancillary PCGs which are included in the simulations and 
are paid on a PCG basis under simulation h 

b{h) = Subset of ancillary PCGs which are included in the simulations but 
are not paid under PCGs under simulation h 

Y(/) = Actual submitted charge or allowed charge for ancillary or inciden- 
tal service 7 

All PCGs which never occur in subset a(/z) or h(h) for any of the simulation are excluded from all 
simulations. 

Thus, the R- for each payment simulation will only be based on payments that are directly related 
to the significant procedure, medical or professional ancillary PCGs. The payment for visits 
assigned to medical PCGs is computed as 

P(/) = BW(g=m)+ ;£ BW(^,f)+ ^ B^ig,t)+ 2^ Y(j) 

where p is the set of professional ancillary PCGs. 

The payment for visits assigned to significant procedure PCGs is computed as 

P(/) = ;^ BD(g,g)W(g,?)+ ^ SW(g,/)+ ^ BW(g,/)+ £ YU) 

t.ges t.g€a(h) i-g^P jeh(h) 

where s is the set of significant procedure PCGs 

The payment for visits which do not have a medical visit or significant procedure but have a pro- 
fessional ancillary is computed as 



The Development of a Physician Prospective Payment System for Ambulatory Care 



277 



Appendix I 



P(/) = ^ BW{g,t)+ ^ BW(g,t)+ "£ YU) 

i.ge p t.ge a(h) j€ h(h) 

The payment simulation will compare historical visit charges (C(/)) to the PCG payment. The his- 
torical visit charges for a visit will be restricted to those charges associated with significant proce- 
dures, medical visits, included ancillaries and professional ancillaries. The charges for incidentals 
are excluded. 

The payment simulations should be budget neutral. Thus, 

•^C(i) = Xp(') 

i I 

The budget neutral multiplier to convert payment weights to dollars is computed as follows 



^CO) = X X BD(g,g)WU,0+ X ^W(g,0+ X BW(g,0+ X ^^^ 

' 1 = ^ r.gea(h) t,gea(h) '.gsp j€b(h) 

+ x|BW(g=m)+ X ^w(g,o+ X BW(g,/)+ X yu) 

ieM r,g€a(h) '. « e p i^Hh) 

x{ X (s^*y+ S BW(g,t)+ X ^o")|| 



Solving for B 



B = 



X c(')- X X ni)\A xj X D(«.^)w(«,o+ X w(g,o+ X w(g,oi 

\eS,M.P I^S.M.P j€b(h) ■' ^ i = S ^t.ge a(h) r.gea(h) r.gep 

+ X{wU=ni)+ X W(g,/)+ X ^(^'')MX |X (8'')^ X ^(8'')}} I 
''eM ;.gea{h) r. g € p ' SeP ^;.g€p f.s€a(A) "'■'•' 

Where S is the set of visits with a significant procedure, M is the set of visits with a medical visit, 
P is the set of visits with a professional ancillary (and no significant procedure of Medical PCGs) 

and A is the set of visits with only ancillaries. Note that Xc(/")andX/'(') should have the same 

value for all simulations based on allowed charges and all simulations based on submitted 
charges. 

For each payment simulation an R^ is computed as follows 

^(p(i)-p)(c{i)-c) 



^ipu)-py^ic(i)-cf 



Where P is the average payment across all visits and C is the average charge across all visits. 
The different options evaluated for ancillaries paid on a PCG basis are 



278 



Final Report 



PCG Payment Simulation Formulas 



No ancillaries paid on a PCG basis 

Limited ancillaries paid on a PCG basis, complete 

Extended ancillaries paid on a PCG basis complete 

For each of the four bases of V(/,g), a payment simulations was performed with and without mul- 
tiple significant procedure discounting (a total of 24 simulations). In addition, payment simula- 
tions using payment weights directly based on RVUs were performed for each of the three options 
with and without significant procedure discounting (6 simulations). There were 30 simulations 
using submitted charges as a dependent variable and 30 using allowed charges as a dependent 
variable. Thus, a total of 60 payment simulations were performed. 

For each of the payment simulations, the PCG relative payment impact (RPI) was computed for 
different subsets of visits 

'^P{i,m)- X^(U) 
RPI(m) = '-^-^ '-^-^ X 100 

i€ H 

where 

RPI(m) = Payment difference between PCG payment model m and 
PCG payment model 1 expressed as a percentage of PCG 
payments under PCG payment model 1 

P(/,m) = Payment for rth patient (visit) under PCG payment model m 

H= Specific subset of patients (visits) 

The subsets of visits for which RPI was computed are 

• Different medical specialties 

• Region of country 

• Urban versus rural 

• Site of service 

• Type of Service 



The Development of a Physician Prospective Payment System for Ambulatory Care 279 



Appendix I 



ens LIBRflRV 




3 ams QDDD3TtD fl 



280 



Final Report